Indiana Medicaid Provider Manual Anthem Blue Cross and Blue Shield
Serving Hoosier Healthwise and Healthy Indiana Plan Anthem Blue Cross and Blue Shield Effective June 1, 2014 Indiana Medicaid Provider Manual For Hoosier Healthwise and Healthy Indiana Plan Programs Version 2.2 June 1, 2014 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Table of Contents CHAPTER 1: INTRODUCTION ..................................................................................14 Welcome....................................................................................................................................................... 14 About This Manual ....................................................................................................................................... 15 Legal Requirements ...................................................................................................................................... 15 Contact Numbers.......................................................................................................................................... 16 Before Rendering Services............................................................................................................................ 16 After Rendering Services .............................................................................................................................. 16 Operational Standards, Requirements & Guidelines ................................................................................... 16 Additional Resources .................................................................................................................................... 16 Using This Manual ........................................................................................................................................ 17 How to Access Information, Forms and Tools on Our Website ................................................................... 17 CHAPTER 2: LEGAL AND ADMINISTRATIVE REQUIREMENTS ...................................18 Proprietary Information ............................................................................................................................... 18 Privacy and Security...................................................................................................................................... 18 Misrouted Protected Health Information .................................................................................................... 18 Updates and Changes ................................................................................................................................... 19 CHAPTER 3: CONTACTS ..........................................................................................20 Overview....................................................................................................................................................... 20 Hoosier Healthwise and Healthy Indiana Plan ............................................................................................. 20 State of Indiana ............................................................................................................................................ 24 CHAPTER 4: COVERED AND NON-COVERED SERVICES ............................................27 Overview....................................................................................................................................................... 27 Hoosier Healthwise....................................................................................................................................... 28 Benefits Matrix for Hoosier Healthwise Services ......................................................................................... 29 Benefits Matrix for Healthy Indiana Plan Services ....................................................................................... 37 Pharmacy Benefits ........................................................................................................................................ 43 Preferred Drug List ....................................................................................................................................... 44 Preferred Drug List: Prior Authorization (PA) Forms .................................................................................... 44 Mandatory Generic Drug Policy ................................................................................................................... 45 Prior Authorization of Prescription Benefits – Full Listing ........................................................................... 45 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 2 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Healthy Indiana Plan: Covered and Non-Covered Drugs.............................................................................. 46 Dental Services (Hoosier Healthwise Only) .................................................................................................. 46 Dental Services: Screening for Dental Problems (Hoosier Healthwise) ....................................................... 46 Dental Services: Dental Referral Procedures (Hoosier Healthwise) ............................................................. 46 Dental Services: Dental Coverage for Accidents (Hoosier Healthwise)........................................................ 47 Vision Services (Hoosier Healthwise) ........................................................................................................... 48 Behavioral Health Services ........................................................................................................................... 48 Hospice Care ................................................................................................................................................. 48 County and State-Linked Services ................................................................................................................ 49 State Services and Programs ........................................................................................................................ 49 Essential Public Health Services ................................................................................................................... 49 Directly Observed Therapy ........................................................................................................................... 50 Reportable Diseases ..................................................................................................................................... 50 WIC Referrals ................................................................................................................................................ 50 CHAPTER 5: BEHAVIORAL HEALTH SERVICES ..........................................................51 Overview....................................................................................................................................................... 51 Goals ............................................................................................................................................................. 51 Objectives ..................................................................................................................................................... 51 Guiding Principles of Anthem’s Behavioral Health Program ........................................................................ 52 Systems of Care ............................................................................................................................................ 53 Coordination of Behavioral Health and Physical Health Treatment ............................................................ 54 Provider Roles and Responsibilities.............................................................................................................. 54 Transition after Acute Psychiatric Care ........................................................................................................ 55 Provider Success ........................................................................................................................................... 55 Health Plan Clinical Staff............................................................................................................................... 55 Coordination of Physical and Behavioral Health Services ............................................................................ 55 Case Management ........................................................................................................................................ 56 Member Records and Treatment Planning: Comprehensive Assessment ................................................... 57 Member Records and Treatment Planning: Personalized Support and Care Plan....................................... 58 Member Records and Treatment Planning: Progress Notes ........................................................................ 58 Psychotropic Medications ............................................................................................................................ 59 Utilization Management ............................................................................................................................... 60 Timeliness of Decisions on Requests for Authorization ............................................................................... 60 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 3 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Access to Care Standards ............................................................................................................................. 60 How to Provide Notification or Request Preauthorization .......................................................................... 61 Necessity Determination and Peer Review .................................................................................................. 61 Non-Medical Necessity Adverse Decisions (Administrative Adverse Decision) ........................................... 62 Provider Appeals, Grievances and Payment Disputes.................................................................................. 62 Avoiding an Adverse Decision ...................................................................................................................... 62 Clinical Practice Guidelines ........................................................................................................................... 62 Emergency Behavioral Health Services ........................................................................................................ 62 Behavioral Health Services: Referral Criteria to Behavioral Health Specialists ............................................ 63 Behavioral Health Services: Criteria for Provider Type Selection................................................................. 63 Links to Forms, Guidelines and Screening Tools .......................................................................................... 64 CHAPTER 6: MEMBER ELIGIBILITY ..........................................................................65 Overview....................................................................................................................................................... 65 How to Verify Member Eligibility ................................................................................................................. 65 Pharmacy Electronic Member Eligibility....................................................................................................... 66 Member ID Cards.......................................................................................................................................... 66 Presumptive Eligibility .................................................................................................................................. 67 Right Choices Program (RCP) ........................................................................................................................ 67 Primary Lock-In Provider Responsibilities in the RCP ................................................................................... 67 Primary Lock-In Hospital Responsibilities in the RCP ................................................................................... 70 CHAPTER 7: UTILIZATION MANAGEMENT ..............................................................72 Utilization Management Staff Availability .................................................................................................... 72 Overview....................................................................................................................................................... 72 Services Requiring Prior Authorization......................................................................................................... 74 Services That Do NOT Require Prior Authorization ...................................................................................... 75 Prior Authorization Toolkit ........................................................................................................................... 75 Starting the Process ...................................................................................................................................... 76 Provider Notifications of Changes to Authorization Procedures ................................................................. 76 Requesting Authorization ............................................................................................................................. 76 Authorization Forms ..................................................................................................................................... 77 Requests with Insufficient Clinical Information ........................................................................................... 78 Pre-Service Review Time Frame ................................................................................................................... 78 Urgent Pre-Service Requests ........................................................................................................................ 78 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 4 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Emergency Medical Conditions and Services ............................................................................................... 79 Emergency Stabilization and Post-Stabilization ........................................................................................... 79 Referrals to Specialists.................................................................................................................................. 80 Out-Of-Network Exceptions ......................................................................................................................... 80 Hospital Inpatient Admissions ...................................................................................................................... 80 Clinical Information for Continued-Stay Review .......................................................................................... 81 Denial of Service ........................................................................................................................................... 82 Post-Service/Retrospective Review .............................................................................................................. 82 Self-Referral .................................................................................................................................................. 82 Second Opinions ........................................................................................................................................... 82 Additional Services: Behavioral Health ........................................................................................................ 83 Additional Services: Vision Care ................................................................................................................... 83 Additional Services: Dental Care .................................................................................................................. 83 CHAPTER 8: HEALTH SERVICES PROGRAMS ............................................................84 Overview....................................................................................................................................................... 84 Preventive Care: Health Screenings & Immunizations ................................................................................. 84 Preventive Care: Initial Health Assessments ................................................................................................ 85 Preventive Care: HealthWatch ..................................................................................................................... 85 Preventive Care: Childhood Lead Exposure Testing/Free Blood Test Kits ................................................... 87 Preventive Care: Member Incentives (Healthy Indiana Plan Only) .............................................................. 87 Health Management: ConditionCare ........................................................................................................... 87 Health Management: ConditionCare for Asthmatic Members .................................................................... 88 Health Management: ConditionCare for Members with Cardiovascular Conditions .................................. 89 Health Management: ConditionCare for Members with Chronic Obstructive Pulmonary Disease (COPD) .......................................................................................................................................................... 90 Health Management: ConditionCare for Diabetic Members ....................................................................... 90 Health Management: Future Moms ............................................................................................................. 91 Health Management: New Mother and Baby Post-Delivery Outreach Program ......................................... 92 Health Education: No-Cost Classes ............................................................................................................... 93 Health Education: 24/7 NurseLine ............................................................................................................... 93 Health Education: Weight Management Programs ..................................................................................... 94 Health Education: Tobacco Treatment Programs ........................................................................................ 94 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 5 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 9: CLAIMS & BILLING...............................................................................97 Overview....................................................................................................................................................... 97 Submitting “Clean” Claims............................................................................................................................ 98 Claims Filing Limits ....................................................................................................................................... 98 Claims from Non-Contracted Providers ....................................................................................................... 99 Methods for Submission............................................................................................................................... 99 Prefixes Required on the CMS-1500 and CMS-1450 Forms ......................................................................... 99 Electronic Claims ........................................................................................................................................ 100 National Provider Identifier ........................................................................................................................ 100 Use of Referring Provider's NPI on Claims Submissions ............................................................................. 101 Unattested NPIs .......................................................................................................................................... 102 Paper Claims ............................................................................................................................................... 102 Paper Claims Processing ............................................................................................................................. 103 Member Copayments and Balance Billing.................................................................................................. 103 Cost-Sharing................................................................................................................................................ 105 Coordination of Benefits ............................................................................................................................ 105 Claims Filed With Wrong Plan .................................................................................................................... 105 Payment of Claims ...................................................................................................................................... 106 Monitoring Submitted Claims .................................................................................................................... 106 Electronic Remittance Advice ..................................................................................................................... 106 Electronic Funds Transfer ........................................................................................................................... 106 Claims Overpayment Recovery Procedure ................................................................................................. 107 Third Party Recovery .................................................................................................................................. 107 Hospital Readmissions Policy ..................................................................................................................... 107 Claims Returned for Additional Information .............................................................................................. 108 Claim Resubmissions .................................................................................................................................. 108 Claims Disputes........................................................................................................................................... 109 Reference: Covered Services ...................................................................................................................... 109 Reference: Clinical Submissions Categories ............................................................................................... 110 Reference: National Drug Codes – Hoosier Healthwise ............................................................................. 111 Reference: Claim Forms & Filing Limits ...................................................................................................... 111 Reference: Other Filing Limits .................................................................................................................... 112 Reference: Common Reasons for Rejected and Returned Claims ............................................................. 113 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 6 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Processes to Resolve Claim Issues .............................................................................................................. 115 CHAPTER 10: BILLING PROFESSIONAL & ANCILLARY CLAIMS ................................ 116 Overview..................................................................................................................................................... 116 Coding ......................................................................................................................................................... 117 National Drug Codes ................................................................................................................................... 117 Initial Health Assessments .......................................................................................................................... 117 Preventive Medicine Services: New Patient ............................................................................................... 118 Preventive Medicine Services: Established Patient .................................................................................... 118 Self-Referable Services ............................................................................................................................... 119 Behavioral Health ....................................................................................................................................... 119 Emergency & Related Professional Services .............................................................................................. 119 Hospital Readmission Policy ....................................................................................................................... 121 Immunizations Covered By Vaccines for Children...................................................................................... 121 Immunizations Not Covered By Vaccines for Children ............................................................................... 121 Additional Services during EPSDT Exams.................................................................................................... 121 Maternity Services ...................................................................................................................................... 122 Billing Requirement for Pregnancy Services............................................................................................... 122 Maternity Services: Claims for Obstetric Deliveries Require a Modifier .................................................... 123 Maternity Services: Cesarean Sections ...................................................................................................... 124 Maternity Services: Newborns ................................................................................................................... 124 Healthy Indiana Plan Maternity Related Services ...................................................................................... 125 Newborns: Circumcision ............................................................................................................................. 125 On-Call Services .......................................................................................................................................... 125 Working After Normal Business Hours ....................................................................................................... 125 Recommended Fields for CMS-1500 .......................................................................................................... 125 CHAPTER 11: BILLING INSTITUTIONAL CLAIMS ..................................................... 127 Overview..................................................................................................................................................... 127 Basic Billing Guidelines ............................................................................................................................... 128 National Drug Codes – Hoosier Healthwise................................................................................................ 128 Billing Requirements by Service Category: Emergency Room Visits .......................................................... 129 Billing Requirements by Service Category: Urgent Care Visits ................................................................... 130 Billing Requirements by Service Category: Maternity ................................................................................ 131 Billing Requirements by Service Category: Inpatient Acute Care .............................................................. 131 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 7 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Billing Requirements by Service Category: Hospital Stays of Less Than 24 Hours ..................................... 132 Billing Requirements by Service Category: Inpatient Sub-Acute Care ....................................................... 132 Billing Requirements by Service Category: Outpatient Laboratory, Radiology and Diagnostic Services ... 133 Billing Requirements by Service Category: Outpatient Surgical Services................................................... 133 Billing Requirements by Service Category: Outpatient Therapies ............................................................. 134 Billing Requirements by Service Category: Outpatient Infusion Therapies and Pharmaceuticals ............. 135 Ancillary Billing: Overview .......................................................................................................................... 135 Ancillary Billing Requirements by Service Category: Ambulance Services ................................................. 136 Ancillary Billing Requirements by Service Category: Ambulatory Surgical Centers ................................... 136 Ancillary Billing Requirements by Service Category: Physical Therapy ...................................................... 136 Ancillary Billing Requirements by Service Category: Speech Therapy ....................................................... 136 Ancillary Billing Requirements by Service Category: Occupational Therapy.............................................. 136 Ancillary Billing Requirements by Service Category: Durable Medical Equipment .................................... 136 Ancillary Billing Requirements by Service Category: DME Rentals ............................................................ 137 Ancillary Billing Requirements by Service Category: DME Purchase.......................................................... 137 Ancillary Billing Requirements by Service Category: DME Wheelchairs/Wheeled Mobility Aids .............. 137 Ancillary Billing Requirements by Service Category: Dialysis ..................................................................... 138 Ancillary Billing Requirements by Service Category: Home Infusion Therapy ........................................... 138 Ancillary Billing Requirements by Service Category: Laboratory and Diagnostic Imaging ......................... 139 Ancillary Billing Requirements by Service Category: Skilled Nursing Facilities .......................................... 139 Ancillary Billing Requirements by Service Category: Home Health Care ................................................... 139 Ancillary Billing Requirements by Service Category: Hospice .................................................................... 139 Additional Billing Resources ....................................................................................................................... 139 Coding Guidelines: The CMS-1450 Claim Form .......................................................................................... 139 Recommended Fields for CMS-1450 (UB-04) ............................................................................................. 140 CHAPTER 12: MEMBER TRANSFERS & DISENROLLMENT ....................................... 144 Overview..................................................................................................................................................... 144 Primary Medical Provider-Initiated Member Transfers ............................................................................. 144 Primary Medical Provider-Initiated Member Disenrollment ..................................................................... 145 Primary Medical Provider-Initiated Member Disenrollment Process ........................................................ 145 State Agency-Initiated Member Disenrollment ......................................................................................... 146 Member-Initiated Primary Medical Provider Transfers ............................................................................. 146 Member Transfers to Other Plans .............................................................................................................. 147 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 8 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Member Disenrollment from the Plan ....................................................................................................... 147 Member-Initiated Disenrollment Process .................................................................................................. 148 CHAPTER 13: GRIEVANCES & APPEALS ................................................................. 149 Overview..................................................................................................................................................... 149 Provider Grievances Relating to the Operation of the Plan ....................................................................... 150 Claims Disputes........................................................................................................................................... 151 Claims Disputes Resolutions ....................................................................................................................... 151 Member Grievances & Appeals .................................................................................................................. 151 Members: When to File .............................................................................................................................. 152 Members: Grievances................................................................................................................................. 153 Members: Grievance Appeals .................................................................................................................... 153 Members: Grievance Appeal Resolutions .................................................................................................. 154 Members Appeals....................................................................................................................................... 154 Member Appeals: Response to Standard Appeals ..................................................................................... 155 Member Appeals: Resolution of Standard Appeals ................................................................................... 155 Member Appeals: Extensions ..................................................................................................................... 156 Member Appeals: Expedited ...................................................................................................................... 156 Member Appeals: Timeline for an Expedited Appeal................................................................................. 156 Member Appeals: Response to Expedited Appeals ................................................................................... 156 Member Appeals: Resolution of Expedited Appeals .................................................................................. 156 Member Appeals: Other Options for Filing Grievances ............................................................................. 157 Member Appeals: External Independent Review....................................................................................... 157 Member Appeals: State Fair Hearing ......................................................................................................... 157 CHAPTER 14: CREDENTIALING & RE-CREDENTIALING ........................................... 159 Credentialing Program Structure................................................................................................................ 159 Credentialing Program Scope ..................................................................................................................... 159 Credentials Committee............................................................................................................................... 160 Nondiscrimination Policy ............................................................................................................................ 161 Initial Credentialing .................................................................................................................................... 161 Re-credentialing ......................................................................................................................................... 162 Health Delivery Organizations .................................................................................................................... 162 Ongoing Sanction Monitoring .................................................................................................................... 163 Appeals Process .......................................................................................................................................... 163 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 9 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Reporting Requirements ............................................................................................................................ 164 Eligibility Criteria – Health Care Practitioners ............................................................................................ 164 Criteria for Selecting Practitioners – New Applicants (Credentialing) ....................................................... 165 Currently Participating Applicants (Re-credentialing) ................................................................................ 167 Additional Participation Criteria and Exceptions for Behavioral Health Practitioners ............................... 169 (Non-Physician) Credentialing .................................................................................................................... 169 Eligibility Criteria – Health Delivery Organizations (HDOs) ........................................................................ 170 CHAPTER 15: ACCESS STANDARDS & ACCESS TO CARE ......................................... 173 Overview..................................................................................................................................................... 173 Medical Appointment Standards: General Appointment Scheduling ........................................................ 173 Medical Appointment Standards: Services for Members under the Age of 21 ......................................... 174 Medical Appointment Standards: Services for Members 21 Years and Older ........................................... 174 Medical Appointment Standards: Prenatal and Postpartum Visits............................................................ 174 Medical Appointment Standards: Missed Appointment Tracking ............................................................. 175 After-Hours Services ................................................................................................................................... 175 Continuity of Care....................................................................................................................................... 176 Provider Contract Termination................................................................................................................... 177 Newly Enrolled............................................................................................................................................ 178 Newly Enrolled - Pregnant .......................................................................................................................... 178 POWER Account Contributions and Change Information .......................................................................... 178 Members Moving Out of Service Area ....................................................................................................... 179 Services Not Available Within Network...................................................................................................... 179 Second Opinions ......................................................................................................................................... 180 Emergency Transportation ......................................................................................................................... 180 Non-Emergency Transportation ................................................................................................................. 180 Emergency Dental Services – Adults & Children ........................................................................................ 181 CHAPTER 16: PROVIDER ROLES & RESPONSIBILITIES ............................................ 182 Overview..................................................................................................................................................... 182 Primary Medical Providers ......................................................................................................................... 182 Referrals ..................................................................................................................................................... 183 Out-Of-Network Referrals .......................................................................................................................... 184 Interpreter Services .................................................................................................................................... 184 Initial Health Assessment ........................................................................................................................... 185 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 10 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Transitioning Members between Facilities or Back Home ......................................................................... 185 Specialists ................................................................................................................................................... 185 Behavioral Health Providers ....................................................................................................................... 186 Behavioral Health Providers – Transition after Acute Psychiatric Care ..................................................... 186 Hospital Scope of Responsibilities .............................................................................................................. 186 Ancillary Scope of Responsibilities ............................................................................................................. 187 Responsibilities Applicable to ALL Providers .............................................................................................. 187 Office Hours ................................................................................................................................................ 188 After-Hours Services ................................................................................................................................... 188 Licenses and Certifications ......................................................................................................................... 189 Eligibility Verification .................................................................................................................................. 189 Collaboration .............................................................................................................................................. 189 Continuity of Care....................................................................................................................................... 189 Medical Records: Standards ....................................................................................................................... 189 Mandatory Reporting of Child Abuse, Elder Abuse or Domestic Violence ................................................ 190 Updating Provider Information .................................................................................................................. 190 Oversight of Non-Physician Practitioners ................................................................................................... 191 Open Clinical Dialogue/Affirmative Statement .......................................................................................... 191 Provider Contract Termination................................................................................................................... 191 Termination of the Ancillary Provider/Patient Relationship ...................................................................... 192 Disenrollees ................................................................................................................................................ 192 Provider Rights ........................................................................................................................................... 192 Prohibited Activities ................................................................................................................................... 192 CHAPTER 17: CLINICAL PRACTICE AND PREVENTIVE HEALTH CARE GUIDELINES ... 194 Overview..................................................................................................................................................... 194 Preventive Health Care Guidelines ............................................................................................................. 194 Clinical Practice Guidelines ......................................................................................................................... 195 CHAPTER 18: CASE MANAGEMENT ...................................................................... 196 Overview..................................................................................................................................................... 196 Role of the Case Manager .......................................................................................................................... 196 Provider Responsibility ............................................................................................................................... 197 Procedures.................................................................................................................................................. 197 Potential Referrals ...................................................................................................................................... 198 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 11 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Referral Process .......................................................................................................................................... 198 Accessing Specialists ................................................................................................................................... 198 Behavioral Health Case Management ........................................................................................................ 198 Behavioral Health Clinical Authorization and Protocols............................................................................. 198 CHAPTER 19: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT ......... 199 Overview..................................................................................................................................................... 199 Quality Improvement Program .................................................................................................................. 201 Healthcare Effectiveness Data and Information Set (HEDIS) ..................................................................... 202 Quality Management.................................................................................................................................. 203 Best Practice Methods................................................................................................................................ 203 Member Satisfaction Surveys ..................................................................................................................... 203 Provider Satisfaction Surveys ..................................................................................................................... 204 Medical Record and Facility Site Reviews .................................................................................................. 204 Medical Record Documentation Standards ............................................................................................... 204 Advance Directives ..................................................................................................................................... 207 Medical Record Review Process ................................................................................................................. 207 Facility Site Review Process ........................................................................................................................ 208 Facility Site Review: Corrective Actions...................................................................................................... 209 Preventable Adverse Events ....................................................................................................................... 209 CHAPTER 20: ENROLLMENT AND MARKETING RULES ........................................... 211 Overview..................................................................................................................................................... 211 Marketing Policies ...................................................................................................................................... 211 Enrollment Process ..................................................................................................................................... 212 CHAPTER 21: FRAUD, ABUSE AND WASTE ............................................................ 214 Overview..................................................................................................................................................... 214 Understanding Fraud, Abuse and Waste.................................................................................................... 214 Examples of Provider Fraud, Abuse and Waste ......................................................................................... 214 Examples of Member Fraud, Abuse and Waste ......................................................................................... 215 Reporting Provider or Recipient Fraud, Abuse or Waste ........................................................................... 215 Anonymous Reporting of Suspected Fraud, Abuse and Waste.................................................................. 216 Investigation Process .................................................................................................................................. 216 Acting on Investigative Findings ................................................................................................................. 217 False Claims Act .......................................................................................................................................... 217 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 12 Table of Contents Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 22: MEMBER RIGHTS & RESPONSIBILITIES ............................................ 218 Overview..................................................................................................................................................... 218 Member Rights ........................................................................................................................................... 218 Member Responsibilities ............................................................................................................................ 220 CHAPTER 23: CULTURAL DIVERSITY & LINGUISTIC SERVICES ................................ 222 Overview..................................................................................................................................................... 222 Interpreter Services .................................................................................................................................... 223 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Table of Contents: Page 13 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 1: INTRODUCTION Welcome Welcome, and thank you for being part of the Anthem Blue Cross and Blue Shield network. Anthem has been selected by the State of Indiana to provide access to health care services for Hoosier Healthwise and the Healthy Indiana Plan Members. Hoosier Healthwise (HHW) is the State of Indiana’s Medicaid program for pregnant women, children and low-income families. The program is separated into packages designed to provide quality care to eligible participants from the following categories: Hoosier Healthwise Package A: For children, some pregnant women and families eligible for Medicaid. Hoosier Healthwise Package C: For preventive, primary and acute care for children under 19 years of age. Hoosier Healthwise Package P: For pregnant women who are found to be Presumptively Eligible (PE) for Medicaid. Package P gives short-term prenatal benefits to pregnant women until determination for Medicaid is complete. The Healthy Indiana Plan (HIP) is an affordable health care program created by the State of Indiana. It began in January 2008 to provide health coverage for low income Hoosier adults. Designed to resemble Health Incentive Plans, the Plan covers adults whose income is no greater than 100% of the Federal Poverty Level (FPL). Actual income can be up to 105% of FPL because 5% is disregarded. HIP emphasizes preventive care and personal responsibility. Except for maternity, vision and dental, HIP offers full benefits, including physician and hospital services, diagnostic services, behavioral health services and prescription drugs. Anthem includes the added benefit of non-emergent transportation for HIP Members. Healthy Indiana Plan Members have a $1,100 deductible, but it is completely offset by the $1,100 POWER Account. POWER Accounts are fully funded on the first day the member is active in a 12 month benefit period. The State and Members provide the funding for the POWER Accounts with Member contributions determined by the State based on income levels. Members required contributions will be no more than 2% of the Members household income. Members have the opportunity to pay their portion by making 12 equal monthly payments. The Member’s employer may pay up to 50% of the Member’s contribution. Community Based Organizations (CBOs) may also pay up to 75% of a Member’s contribution. Healthy Indiana Plan: For adults between the ages of 19 and 64 who do not qualify for Medicare Parts A, B and/or D, and are not covered by any other group or individual health plan. There is no coordination of benefits. Members who become covered under other qualifying coverage are terminated from HIP. There are no maternity benefits under HIP. HIP Members who become pregnant must submit proof of pregnancy and a change form to move to Hoosier Healthwise for full coverage during their pregnancy. They must submit a new application for HIP after their pregnancy ends. When a miscarriage occurs before a Healthy Indiana Plan member has moved to Hoosier Healthwise, the Healthy Indiana Plan will pay the related claims. We will also go back and pay any other pregnancy related claims that have been denied due to the pregnancy exclusion. Providers should contact us through the Provider Helpline or submit a written request when there isn’t a claim submitted for spontaneous abortion or miscarriage to trigger adjustments of previous maternity related claims. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 1: Page 14 Chapter 1: Introduction Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan For Hoosier Healthwise and the Healthy Indiana Plan, Anthem's commitment is to ensure access to primary and preventive care services, improve access to all necessary health care services, encourage coordination of medical care, emphasize prevention and education, and provide first-class customer service. At Anthem, we're proud of our Practice Consultants who are registered nurses, working with our network healthcare providers to maximize health care services for our Members. The Practice Consultants are in the field and see providers on a regular basis. They coordinate with our Provider Network Representatives and Community Outreach Representatives, who are also in the field. Together, they link Providers, Members and community agencies to Anthem resources and provide support and assistance to Providers to best serve Anthem Members. Anthem team members are available to: Provide training for health care professionals and their staff regarding enrollment, covered benefits, managed care operations and linguistic services. Provide Member support services, including health education referrals, event coordination, and coordination of cultural and linguistic services. Coordinate access to community health education resources for breastfeeding, smoking cessation, diabetes and asthma, to name just a few. There is strength in numbers: Our health services programs, combined with those already available in the community, are designed to supplement Providers' treatment plans and improve our Members' overall health. They do so by informing, educating and encouraging self-care in the prevention, early detection and treatment of existing conditions and chronic disease. About This Manual This Provider Manual is designed for network physicians, hospitals and ancillary Providers. Our goal is to create a useful reference guide for you and your office staff. We want to help you navigate our managed health care plan to find the most reliable, responsible, timely and cost-effective ways to deliver quality health care to our Members. We recognize that managing our Members’ health can be a complex undertaking. It requires familiarity with the rules and regulations of a system that includes a wide array of health care services and responsibilities, including from initial health assessments to case management and from proper storage of medical records to billing for emergencies. With that in mind, we’ve divided this manual into broad sections that reflect your questions, concerns and responsibilities before and after a Hoosier Healthwise or Healthy Indiana Plan Member walks through your doors. The sections are conceived as follows: Legal Requirements Contact Numbers Before Rendering Services After Rendering Services Operational Standards, Requirements & Guidelines Additional Resources Legal Requirements Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 1: Page 15 Chapter 1: Introduction Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The information contained in this manual is proprietary, will be updated regularly and is subject to change. This section provides specific information on the legal obligations of being part of the Anthem network. Contact Numbers This section is your ready reference for important contact numbers, websites and mailing addresses. Before Rendering Services This section provides the information and tools you'll need before providing services, including Member Eligibility and a list of Covered and Non-Covered Services. It also includes a chapter on the Prior Authorization process and the coordination of complex care through Care Management. We take pride in our pro-active approach to health. The chapter on Health Services programs details how we can partner with you to make the services you provide more effective. For example, the Initial Health Assessment is our first step in providing information regarding preventive care. The ER Initiative is aimed at promoting proper use of emergency room services. And Condition Care, a special grouping of health services programs, allows us to collaborate with you in combating the most common and serious conditions and illnesses facing our Members, including cardiovascular disease, diabetes and asthma. After Rendering Services At Anthem, our goal is to make the billing process as streamlined as possible. This section provides guidelines and detailed coding charts for fast, secure and efficient Billing, including specific information on filing claims for professional and institutional services. In addition, the Member Transfers chapter outlines the steps for Members who want to change their assignment of Primary Medical Provider or transfer to another health plan. When there are questions or concerns about a claim determination or questions regarding access to care, our chapter on Grievances and Appeals will take you step-by-step through the process. Operational Standards, Requirements & Guidelines This section summarizes the requirements for Provider office operations, including Access Standards, which ensure across-the-board consistency when Members need to consult with Providers for Initial Health Assessments, referrals, coordination of care and follow-up care. Separate chapters detail Provider Credentialing, Provider Roles & Responsibilities and Enrollment & Marketing guidelines. Chapters on Clinical Practice & Preventive Health Guidelines and Case Management outline the steps Providers should take to coordinate care and help Members take a proactive stance in the fight against disease. And finally, there is a chapter on our commitment to participate in Quality Assessments, which helps Anthem continually measure, compare and improve our standards of care. Additional Resources To help Providers serve a diverse and ever-evolving patient population, we have created a cultural competency tool kit titled Caring for Diverse Populations to help improve Provider/Member communications by cutting through language and other cultural barriers. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 1: Page 16 Chapter 1: Introduction Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan In addition, Anthem works with nationally recognized health care organizations to stay current on the latest health care breakthroughs and discoveries. This manual provides easy links to access that information. We also provide forms and reference guides you’ll need on a wide variety of subjects. Using This Manual This manual is provided to you under Provider Communications on the Provider Resources page of our website at www.anthem.com. For specific instructions on how to access the online version of this manual, as well as the extensive collection of tools, information and forms available to you on our website, please see How to Access Information, Forms and Tools on Our Website below. Click on any topic in the Table of Contents and you will be taken directly to that topic. Click on any web address and you will be redirected to that site. Each chapter may also contain cross-links to other chapters, to our website or to outside websites containing additional information. Icons, bold type, or boxes may draw attention to important information. Unless otherwise specifically noted, the information in the manual applies to both the Hoosier Healthwise and Healthy Indiana Plan programs. If you have any questions about the content of this manual, contact our Provider Helpline at: Hoosier Healthwise: 1-866-408-6132 Healthy Indiana Plan: 1-800-345-4344 How to Access Information, Forms and Tools on Our Website A wide array of tools, information and forms are accessible via the Provider Resources page of our website, www.anthem.com. Throughout this manual, we will often refer you to items located on the Provider Resources page. To access this page, please follow these websteps: 1. Go to www.anthem.com 2. Select OTHER ANTHEM WEBSITES: Providers 3. Select Providers | Spotlight: State Sponsored Plans – Indiana Hoosier Healthwise and Healthy Indiana Plan 4. Select Indiana Hoosier Healthwise and Healthy Indiana Plan (HIP) Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 1: Page 17 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 2: LEGAL AND ADMINISTRATIVE REQUIREMENTS Legal and Administrative Requirements Proprietary Information The information contained in this Provider Manual is proprietary. By accepting this manual, Anthem Providers agreeto protect and hold the manual’s information as proprietary to Anthem To use this manual solely for the purposes of referencing information regarding the provision of medical services to Hoosier Healthwise and/or Healthy Indiana Plan Members enrolled for services through Anthem Blue Cross and Blue Shield (herein referenced as “Anthem” or the “Plan”). Legal and Administrative Requirements Privacy and Security Anthem’s latest Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant privacy and security statements can be found under on the Provider Resources page of our website at www.anthem.com. To read them, please scroll down to Standards and Policies and select Notice of Privacy Practices (NOPP). Throughout this manual, there are instances where information is provided as an example. Because actual situations may vary, this information is meant to illustrate, and is not intended to be used or relied upon. There are also places within the manual where you may be invited to leave the Anthem site and enter another site operated by a third party. These links are provided for your convenience and reference only. Anthem and its subsidiary companies do not control such sites and do not necessarily endorse them. Anthem is not responsible for their content, products or services. Please be aware that when you travel from the Anthem site to another site, whether through links provided by Anthem or otherwise, you will be subject to the privacy policies (or lack thereof) of the other sites. Anthem cautions you to determine the privacy policy of such sites before providing any personal information. Legal and Administrative Requirements Misrouted Protected Health Information Providers and facilities are required to review all Member information received from Anthem to ensure no misrouted Protected Health Information (PHI) is included. Misrouted PHI includes information about Members that a Provider or facility is not treating. PHI can be misrouted to Providers and facilities by mail, fax, e-mail, or electronic Remittance Advice. Providers and facilities are required to destroy immediately any misrouted PHI or safeguard the PHI for as long as it is retained. In no event are Providers or facilities permitted to misuse or re-disclose misrouted PHI. If Providers or facilities cannot destroy or safeguard misrouted PHI, please contact the Provider Helpline at: Hoosier Healthwise: 1-866-408-6132 Healthy Indiana Plan: 1-800-345-4344. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 2: Page 18 Chapter 2: Legal and Administrative Requirements Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Legal and Administrative Requirements Updates and Changes The Provider Manual, as part of your Provider Agreement and related Addendums, may be updated at any time and is subject to change. In the event of an inconsistency between information contained in the manual and the Agreement between you or your facility and Anthem, the Agreement shall govern. In the event of a material change to the Provider Manual, we will make all reasonable efforts to notify you in advance of such change through web-posted newsletters, fax communications, and other mailings. In such cases, the most recently published information should supersede all previous information and be considered the current directive. The manual is not intended to be a complete statement of all Anthem policies or procedures. Other policies and procedures not included in this manual may be posted on our website or published in specially targeted communications, including but not limited to bulletins and newsletters. This manual does not contain legal, tax or medical advice. Please consult your own advisors for advice on these topics. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 2: Page 19 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 3: CONTACTS Hoosier Healthwise Anthem Medicaid Provider Helpline Phone: 1-866-408-6132 Anthem Medicaid Provider Helpline Fax: 1-866-408-7087 Hours of Operation: Monday to Friday, 7am-7pm Healthy Indiana Plan Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Contacts Overview The following resource grid is a consolidation of the most-used phone and fax numbers, websites and addresses found within the manual itself. We've also included other valuable contact information for you and your staff. The first chart below gives you contact information for Hoosier Healthwise and the Healthy Indiana Plan. The second chart is contact information for the health services programs handled by the state. Contacts Hoosier Healthwise and Healthy Indiana Plan Contact Information for Hoosier Healthwise and Healthy Indiana Plan If you have questions about… Hoosier Healthwise (HHW) Healthy Indiana Plan (HIP) Address General address for all correspondence other than initial claims submittals: Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 Note: For faster service, please also indicate how you want it routed – for example: "Attn: Claims Follow-Up." General address for all correspondence other than initial claims submittals: Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 Note: For faster service, please also indicate how you want it routed – for example: "Attn: Claims Follow-Up." Authorization Utilization Management Department 1-866-408-7187 Monday to Friday, 8am-5pm Fax: 1-866-406-2803 www.anthem.com (to request authorization for services prior to being rendered and hospital/facility admission notification) Utilization Management Department 1-866-408-7187 Monday to Friday, 8am- 5pm Fax: 1-866-406-2803 www.anthem.com Behavioral Health Services Anthem Medicaid Provider Helpline Anthem Provider Helpline 1-866-408-6132 Fax: 1-800-376-0247 1-800-345-4344 Fax: 1-800-376-0247 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 3: Page 20 Chapter 3: Contacts Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Contact Information for Hoosier Healthwise and Healthy Indiana Plan If you have questions about… Hoosier Healthwise (HHW) Healthy Indiana Plan (HIP) Benefits, eligibility, Primary Medical Provider verification and general provider questions Please refer to the State Contacts Table for Indiana's Web interChange and Indiana Health Coverage Programs information. Anthem Medicaid Provider Helpline 1-866-408-6132 TTY: 1-866-408-7188 Monday to Friday, 7am-7pm Fax: 1-866-408-7087 Call 24/7 NurseLine (see below) afterhours to verify Member eligibility. Please refer to the State Contacts Table for Indiana's Web interChange and Indiana Health Coverage Programs information. Anthem Provider Helpline1-800-345-4344 TTY: 1-866-408-7188 Monday to Friday, 7am-7pm Fax: 1-800-376-0247 Call 24/7 NurseLine (see below) after-hours, to verify Member eligibility. Case Management Referrals 1-866-408-7187 Monday to Friday, 8am-5pm Fax: 1-866-387-2959 Response within three business days 1-866-408-7187 Monday to Friday, 8am-5pm Fax: 1-866-387-2959 Response within three business days Claims Log in to www.availity.com and follow instructions to register. Hours of operation: 24 Hours a Day, 7 Days a Week Anthem Medicaid Provider Helpline 1-866-408-6132 Monday to Friday, 7am-7pm Claims address (initial claims only) Attn: Claims Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 Log in to www.availity.com and follow instructions to register. Hours of operation: 24 Hours a Day, 7 Days a Week Anthem Provider Helpline 1-800-345-4344 Monday to Friday, 7am-7pm Claims address (initial claims only) Attn: Claims Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 Claims Overpayment Mail overpayment to: Overpayment Recovery Anthem Blue Cross and Blue Shield P.O. Box 92420 Cleveland, OH 44193 For overnight delivery: Overpayment Recovery Anthem Blue Cross and Blue Shield Lockbox 92420 4100 West 150th Street Cleveland OH 44135 Mail overpayment to: Overpayment Recovery Anthem Blue Cross and Blue Shield P.O. Box 92420 Cleveland, OH 44193 For overnight delivery: Overpayment Recovery Anthem Blue Cross and Blue Shield Lockbox 92420 4100 West 150th Street Cleveland OH 44135 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 3: Page 21 Chapter 3: Contacts Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Contact Information for Hoosier Healthwise and Healthy Indiana Plan If you have questions about… Hoosier Healthwise (HHW) Healthy Indiana Plan (HIP) Contracting 1-800-455-6805 Monday to Friday, 8am-5pm 1-800-455-6805 Monday to Friday, 8am-5pm Practice Consultants, Provider Network Representatives or Community Resource Coordinators Central................................1-866-795-5440 Monday to Friday, 8am-5pm Dental Services IHCP Customer Assistance Unit (Hoosier Healthwise Only) 1-317-655-3240 or 1-800-577-1278 Electronic Data Interchange Anthem EDI Solutions Helpdesk: 1-800-470-9630 Monday to Friday, 8am-4:30pm Eastern Time EDI Solutions E-mail: [email protected] Website: www.anthem.com/edi Enrollment Hoosier Healthwise Enrollment Healthy Indiana Plan Call Center 1-800-889-9949 1-877-GET-HIP-9 (1-877-438-4479) www.HIP.IN.gov Hoosier Healthwise Enrollment website E-mail: [email protected] Anthem Medicaid Provider Helpline Anthem Provider Helpline 1-866-408-6132 Fax: 1-866-408-7087 1-800-345-4344 Special Investigations Unit Special Investigations Unit 1-877-283-1524 1-877-283-1524 1-866-408-7187 1-866-408-7187 Fax: 1-866-387-2968 Fax: 1-866-387-2968 24 hours a day, 7 days a week 24 hours a day, 7 days a week Member Interpreter Services Anthem Medicaid Provider Helpline Anthem Provider Helpline 1-866-408-6132 (Provider) 1-800-345-4344 (Provider) (Available over the phone and face to face) Customer Care Center Customer Care Center 1-866-408-6131 (Member) 1-866-408-6131 (Member) Lead Exposure Testing Kits MEDTOX Laboratories MEDTOX Laboratories 1-888-834-8315 1-888-834-8315 Special Investigation Unit Grievances & Appeals Representatives are located throughout the State and can be reach through our central number www.indianamedicaid.com Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Fax: 1-800-376-0247 Version 2.2 June 1, 2014 Chapter 3: Page 22 Chapter 3: Contacts Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Contact Information for Hoosier Healthwise and Healthy Indiana Plan If you have questions about… Hoosier Healthwise (HHW) Healthy Indiana Plan (HIP) Members with hearing or speech loss Relay Indiana Relay Indiana 1-800-743-3333 or 711 1-800-743-3333 or 711 24 hours a day, 7 days a week 24 hours a day, 7 days a week Nurse Help Line 24/7 NurseLine 24/7 NurseLine 1-866-800-8780 1-866-800-8780 TTY: 1-800-368-4424 TTY: 1-800-368-4424 24 hours a day, 7 days a week, and available after normal business hours to verify Member eligibility or to obtain over the phone interpreter assistance after normal business hours 24 hours a day, 7 days a week, and available after normal business hours to verify Member eligibility or to obtain over the phone interpreter assistance after normal business hours Pharmacy – Auditing, Authorization Requests, Preferred Drug Lists and Claims Processing Catamaran Clinical and Technical Help DeskPharmacy Services Point of Sale (POS), Member and Provider Inquiries, Pharmacy Claims Processing, Pharmacy Clinical Inquiries and Requests for Pharmacy Prior Authorizations 1-855-577-6317 24 hours a day, 7 days a week E-mail: [email protected] Catamaran Clinical and Technical Help Desk Pharmacy Point of Sale (POS), Member and Provider Inquiries, Pharmacy Claims Processing, Pharmacy Clinical Inquiries and Requests for Pharmacy Prior Authorizations 1-855-577-6317 E-Mail: [email protected] Transportation (non- emergency) LCP Transportation, LLC Schedule appointments: 1-800-508-7230 Monday to Friday, 8am-5pm After-hours service 1-888-732-2097 Fax: 1-317-291-9466 24 hours a day, 7 days a week www.lcptransportation.com Transportation-related grievance and appeals: Attn: Appeals Department LCP Transportation 4308 Guion Road, Suite D Indianapolis, IN 46254 LCP Transportation, LLC Schedule appointments: 1-800-508-7230 Monday to Friday, 8am-5pm After-hours service: 1-888-732-2097 Fax: 1-317-291-9466 24 hours a day, 7 days a week www.lcptransportation.com Transportation-related grievance and appeals: Attn: Appeals Department LCP Transportation 4308 Guion Road, Suite D Indianapolis, IN 46254 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 3: Page 23 Chapter 3: Contacts Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Contact Information for Hoosier Healthwise and Healthy Indiana Plan If you have questions about… Hoosier Healthwise (HHW) Vision Services Vision Service Plan (VSP) www.vsp.com Claims and membership questions: 1-800-615-1883 For Members: 1-866-866-5641 TTY: 1-800-428-4833 Monday to Friday, 7am-7pm (Hoosier Healthwise Only) Healthy Indiana Plan (HIP) Contacts State of Indiana Contact Information for the State of Indiana If you have questions about…. Contact Information Breastfeeding Support Line 1-800-231-2999 Children's Special Health Care Services (CSHCS) www.in.gov/isdh/19613.htm Dental Services: Indiana Health Coverage Program (IHCP) (Hoosier Healthwise Only) 1-317-655-3240 1-800-577-1278 Enrollment Hoosier Healthwise: 1-800-889-9949 Healthy Indiana Plan Call Center: 1-877-GET-HIP-9 www.HIP.IN.gov Email: [email protected] Grievances & Appeals: State Fair Hearing Indiana Family and Social Services Administration (FSSA) FSSA Hearing and Appeals Section MS-04 402 W. Washington St. Room W392 Indianapolis, IN 46204-2773 1-317-233-4454 Grievances & Appeals: Mediation & Arbitration Indiana Family and Social Services Administration (FSSA) FSSA Hearing and Appeals Section MS-04 402 W. Washington St. Room W392 Indianapolis, IN 46204-2773 1-317-233-4454 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 3: Page 24 Chapter 3: Contacts Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Contact Information for the State of Indiana If you have questions about…. Contact Information Hearing or Speech Loss: Relay Indiana 1-800-743-3333 or 711 Hoosier Healthwise Helpline (Operated by Indiana Family and Social Services Administration- FSSA) Helpline: 1-800-889-9949 Indiana Division of Disability and Rehabilitation Services (DDRS) www.in.gov/fssa/2328.htm Indiana Division of Mental Health and Addiction (DMHA) www.in.gov/fssa/dmha/4521.htm Indiana Family and Social Services Administration (FSSA) Indiana Family and Social Services Administration (FSSA) 402 W. Washington St. Room W374, MS07 Indianapolis, IN 46204-2739 1-317-655-3240 Email: [email protected] Indiana Health Coverage Program (IHCP) Automated Voice Response: Indianapolis Area: 1-317-692-0819 Other Areas: 1-800-738-6770 Customer Care Center: 1-800-553-2019 Monday to Friday, 7am-8pm Website: http://provider.indianamedicaid.com/become-a-provider/ihcpprovider-enrollment-transactions.aspx Indiana Tobacco Quitline 1-800-784-8669 Pharmacy Services: State of Indiana 1-800-457-4584 Pharmacy Services: Preferred Drug List www.indianamedicaid.com Click on: Pharmacy Services State of Indiana Medicaid Providers Website http://provider.indianamedicaid.com/ Web interChange https://interchange.indianamedicaid.com/Administrative/logon.aspx Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 3: Page 25 Chapter 3: Contacts Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Contact Information for the State of Indiana If you have questions about…. Contact Information Women, Infants and Children (WIC) Program 1-800-522-0874 www.in.gov/isdh/24777.htm Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 3: Page 26 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 4: COVERED AND NON-COVERED SERVICES Hoosier Healthwise: Anthem Medicaid Provider Helpline Phone: 1-866-408-6132 Anthem Medicaid Provider Helpline Fax: 1-866-408-7087 Hours of Operation: Monday to Friday, 7am-7pm Healthy Indiana Plan: Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Pharmacy Services: State of Indiana Phone: 1-855-577-6317 Dental Services: Indiana Health Coverage Program (IHCP) Phone: 1-317-655-3240 or 1-800-577-1278 Website: www.indianamedicaid.com Vision Services: Vision Service Plan (VSP) Phone: 1-866-866-5641 Website: www.vsp.com Covered and Non-Covered Services Overview This chapter outlines some of the specific covered and non-covered services for Hoosier Healthwise and the Healthy Indiana Plan. For a complete list of covered and non-covered services see Chapter 2 of the IHCP Manual at http://provider.indianamedicaid.com/ihcp/manuals/chapter02.pdf. Hoosier Healthwise, the managed care program for Indiana children, pregnant women and low-income working families, is divided into packages: Hoosier Healthwise Package A: For children, pregnant women and families eligible for Medicaid. Hoosier Healthwise Package C (CHIP): For preventive, primary and acute care for children under 19 years of age. Hoosier Healthwise Package P: For pregnant women who are found to be Presumptively Eligible (PE) for Medicaid. Package P gives short-term benefits to pregnant women until determination for Medicaid is complete. The Healthy Indiana Plan is for adults between the ages of 19-64 who are not covered by Medicare Parts A, B and/or D and are not covered by any other qualifying medical insurance. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 27 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Covered and Non-Covered Services Hoosier Healthwise Hoosier Healthwise Packages A & C cover the following services: Behavioral Health: Inpatient, Outpatient & Partial Hospital Stay Chiropractic Diabetes Self-Management Family Planning Home Health Care Hoosier HealthWatch Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Hospital Services: Inpatient & Outpatient Lab & Radiology Medical Supplies & Equipment Nurse-Midwife Services Nurse Practitioner Services Organ Transplants (excluding Package C) Physician Services Podiatry Services Preventive Care Rehab Services: Inpatient Respiratory Therapy Skilled Nursing Facility Smoking Cessation Speech, Hearing and Language Disorders Substance Abuse: Inpatient, Outpatient & Partial Hospital Stay Therapy Transportation: Emergency & Non-Emergency Vision Services (excluding Healthy Indiana Plan Members) Hoosier Healthwise Package P is the managed care program for women who are Presumptively Eligible for Medicaid. To qualify for Presumptive Eligibility, a potential Member must: Be an Indiana resident Be a U.S. citizen Be pregnant Have a gross family income of less than 200% of the federal poverty level Not be a Hoosier Healthwise Member Not be in prison Package P covers outpatient services related to pregnancy, including: Prenatal Care Services Services related to conditions that may cause pregnancy problems Hoosier Healthwise Package P does not cover: Abnormal Products of Conception Abortion Contraception Ectopic Pregnancy Services Hospice Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 28 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Inpatient Hospital Services Labor & Delivery Services Long-Term Care Postpartum Care Sterilization Covered and Non-Covered Services Benefits Matrix for Hoosier Healthwise Services Please Note: Providers contracted with Anthem to serve Hoosier Healthwise and the Healthy Indiana Plan through an Accountable Care Organization (ACO), Participating Medical Group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative. For a complete list of covered and non-covered services see Chapter 2 of the IHCP Manual at http://provider.indianamedicaid.com/ihcp/manuals/chapter02.pdf. Hoosier Healthwise (Packages A and C) Benefits/Limitations Package A Coverage Package C Coverage Behavioral Health – Inpatient Services given in a certified psychiatric hospital or an acute care hospital Services given in a certified psychiatric hospital or an acute care hospital Behavioral Health Outpatient Psychotherapy (group, family and individual) Psychotherapy (group, family and individual) Psychological and neuropsychological tests Psychological and neuropsychological tests Psychiatric diagnosis interview, exam and treatment Psychiatric diagnosis interview, exam and treatment Chiropractic Up to 5 visits per year Up to 5 visits per year Note: Package B coverage limited to services related to pregnancy, conditions that may complicate the pregnancy, or urgent care 50 therapeutic physical medicine treatments per year 14 therapeutic physical medicine treatments per year (Up to 36 more treatments available with prior authorization). Requires Prior Authorization Requires Prior Authorization Dental One full spine X-ray per year One full spine X-ray per year Covered by Indiana Medicaid Covered by Indiana Medicaid Refer to www.indianamedicaid.com Refer to www.indianamedicaid.com Diabetes Self-management training Nutrition and exercise advice Nutrition and exercise advice Benefit covers a total of 4 hours per year. Additional may be authorized upon request. Drug advice Drug advice Blood sugar self-check Blood sugar self-check Insulin shot Insulin shot Foot, skin, dental care Foot, skin, dental care Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 29 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Hoosier Healthwise (Packages A and C) Benefits/Limitations Package A Coverage Package C Coverage Family Planning Education and advice Education and advice Counseling Counseling Physical exam Physical exam Annual cervical cancer screening Annual cervical cancer screening Birth control Birth control Follow-up care Follow-up care Pregnancy tests Pregnancy tests Sterilization Sterilization Lab tests Lab tests Sexually transmitted infection screenings Sexually transmitted infection screenings HIV screening, testing and counseling for at-risk Members; referrals for treatment HIV screening, testing and counseling for at-risk Members; referrals for treatment HIV/AIDS Case Management Assessment Does not apply to Package C Note: Benefits apply to Package B Members only Plan of Care Development Consults Periodic evaluations Home Health Care Skilled Nursing Services Skilled Nursing Services Physical, occupational, speech and respiratory therapy Physical, occupational, speech and respiratory therapy Renal dialysis Renal dialysis For Members up to 21 years of age: For Members under 19 years of age: Health and Development history exam Health and Development history exam Physical exam Physical exam Vaccines Vaccines Lab test including blood lead screenings Lab test including blood lead screenings Health Education Health Education Requires Prior Authorization Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 30 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Hoosier Healthwise (Packages A and C) Benefits/Limitations Package A Coverage Package C Coverage Hospital Services Inpatient Shared room (unless private room is medically-necessary) Shared room (unless private room is medically-necessary) Requires Prior Authorization Special unit care Special unit care Operating, delivery, special treatment room Operating, delivery, special treatment room Supplies Supplies Medical tests Medical tests Inpatient stay prescriptions Inpatient stay prescriptions Inpatient oxygen Inpatient oxygen Blood transfusions and products Blood transfusions and products Radiation/Chemotherapy Radiation/Chemotherapy Dialysis Dialysis Meals and special diets Meals and special diets Regular nursing care Regular nursing care Special duty nursing when necessary Special duty nursing when necessary Surgery Surgery Anesthesia Anesthesia Breathing therapy Breathing therapy Diagnostic services Diagnostic services Overnight stay for dental work if need is severe or another health issue is present Overnight stay for dental work if need is severe or another health issue is present Discharge planning Discharge planning Emergency room use and observations stays Emergency room use and observations stays Emergency dental services for children under the age of 21 Emergency dental services for children under the age of 21 Outpatient surgeries Outpatient surgeries Radiation therapy and/or chemotherapy Radiation therapy and/or chemotherapy Dialysis Dialysis Physical, occupational and speech therapy Physical, occupational and speech therapy X-Rays and Lab tests X-Rays and Lab tests Drugs/Supplies Drugs/Supplies Emergency Services Requires Prior Authorization Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 31 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Hoosier Healthwise (Packages A and C) Benefits/Limitations Package A Coverage Package C Coverage Lab and Radiology Lab and X-ray services Lab and X-ray services Requires Prior Authorization Mammograms Mammograms CT scans and MRIs CT scans and MRIs PET and SPECT scans PET and SPECT scans Shared room (unless private room is medically-necessary) Shared room (unless private room is medically-necessary) Supplies Supplies Medical tests Medical tests Inpatient stay prescriptions Inpatient stay prescriptions Inpatient oxygen Inpatient oxygen Meals and special diets Meals and special diets Regular nursing care Regular nursing care Special duty nursing when necessary Special duty nursing when necessary Anesthesia Anesthesia Breathing therapy Breathing therapy Discharge planning Discharge planning Covered when medically necessary Covered when medically necessary. DME coverage limited by a maximum benefit of $2000 per year or $5000 per lifetime. Well-woman care Well-woman care Family planning Family planning Pregnancy care Pregnancy care Long term Acute Care Requires Prior Authorization Medical Supplies Durable Medical Equipment (DME) Custom-made DME requires Prior Authorization Nurse-midwife services o o o Nurse practitioner services Prenatal care Labor and delivery Post-partum care Services that are medically necessary or for preventative care Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan o o Prenatal care Labor and delivery Post-partum care Services that are medically necessary or for preventative care Version 2.2 June 1, 2014 Chapter 4: Page 32 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Hoosier Healthwise (Packages A and C) Benefits/Limitations Package A Coverage Package C Coverage Organ Transplants Kidney Does not apply to Package C Requires Prior Authorization Kidney/pancreas Liver Bone Marrow Cornea Small intestine Multivisceral Heart Lung Heart/Lung Pharmacy Physician Surgical and Medical Services Podiatry Services Covered by Indiana Medicaid Covered by Indiana Medicaid For coverage and limitations, please refer to Chapter 9: IHCP Pharmacy Services Benefit in the IHCP Manual at http://provider.indianamedicaid.co m/general-providerservices/manuals.aspx For coverage and limitations, please refer to Chapter 9: IHCP Pharmacy Services Benefit in the IHCP Manual at http://provider.indianamedicaid.com /general-providerservices/manuals.aspx Diagnostic Diagnostic Preventive Care Preventive Care Pain relief for terminal illness Pain relief for terminal illness Therapy Therapy Rehab Rehab Member is covered for 4 Primary Medical Provider office visits per month or 20 per year. More may be approved if medically necessary. Member is covered up to 30 Primary Medical Provider office visits per rolling 12-month period without prior authorization. More may be approved if medically necessary. Foot Surgery Foot Surgery Lab Tests Lab Tests X-rays X-rays Inpatient hospital stay when medically necessary Inpatient hospital stay when medically necessary Member is covered for up to 6 routine foot care visits per year Routine foot care is not covered Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 33 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Hoosier Healthwise (Packages A and C) Benefits/Limitations Package A Coverage Package C Coverage Rehab Services Inpatient Assistance with: Assistance with: Requires Prior Authorization Attention Attention Memory Memory Communication Communication Bladder or Bowl problems Bladder or Bowl problems Walking Climbing Walking Climbing Using a wheelchair Using a wheelchair Pain Management Pain Management Self-care Self-care Coverage is limited to 50 days per calendar year Respiratory Therapy Review of and treatment for breathing problems Review of and treatment for breathing problems Inpatient or Outpatient care for Members with severe heart or lung problems Inpatient or Outpatient care for Members with severe heart or lung problems Coverage is limited to 50 sessions per rolling 12-month period Skilled Nursing Facility Short term Psychiatric hospitals Benefit does not apply to Package C Shared room (unless private room is medically necessary) Nursing Care Medical supplies and equipment Physical, occupational, breathing and speech therapy Coverage limited to a maximum of 30 days when medically necessary for skilled level of care Smoking Cessation One 12-week course of treatment per 12 months that includes: One 12-week course of treatment per 12 months that includes: Prescription or over-the-counter smoking cessation products (for up to 24 weeks per rolling 12 month period) Prescription or over-the-counter smoking cessation products (for up to 24 weeks per rolling 12 month period) Limited to 8 hours of counseling services per rolling 12-month period Limited to 8 hours of counseling services per rolling 12-month period Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 34 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Hoosier Healthwise (Packages A and C) Benefits/Limitations Package A Coverage Package C Coverage Speech, hearing and language disorders Speech and language services include group therapy and treatment for a single Member with these limits: Speech and language services include group therapy and treatment for a single Member with these limits: Hearing services include 1 exam by a licensed audiologist every 3 years Limit of 3 hours of service per evaluation Up to 25 sessions per calendar year Prior Authorization not required for services given within 30 days after discharge from a hospital Substance Abuse Services Inpatient Limit of 50 visits per rolling year per type of therapy Hearing services include 1 exam by a licensed audiologist every 3 years Services given in a psychiatric hospital or acute care hospital Services for Members treated in an acute care hospital Group, family and individual psychotherapy Group, family and individual psychotherapy Facility-based services requiring inpatient stay Facility-based services requiring inpatient stay Limited to 25 sessions per type of therapy per calendar year Limited to 50 visits per year per type of therapy No prior authorization needed if therapy occurs within 30 days of hospital discharge No prior authorization needed if therapy occurs within 30 days of hospital discharge Emergency transport to get medical care and treatment in a true emergency Emergency transport by ambulance to get medical care and treatment in a true emergency Non-emergency transport for medical care. Ambulance transport between facilities when medically necessary ($10 copay applies for each ambulance transport) Requires Prior Authorization Substance Abuse Services Outpatient Requires Prior Authorization after 13 sessions Substance Abuse Services – Partial hospital stay Therapy Transportation Benefit does not cover transport to pharmacies Non-emergency transport for medical care. Benefit does not cover transport to pharmacies Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 35 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Hoosier Healthwise (Packages A and C) Benefits/Limitations Package A Coverage Package C Coverage Vision Services One eye exam every 12 months for Members of all ages One eye exam every 12 months for Members of all ages One pair of glasses per year for Members through age 20 One pair of glasses per year for Members through age 20 One pair of glasses every 60 months for Members age 21 and older Contact lenses (when medically necessary) Contact lenses (when medically necessary) Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 36 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Covered and Non-Covered Services Benefits Matrix for Healthy Indiana Plan Services Please Note: Providers who are contracted with Anthem to serve Hoosier Healthwise and the Healthy Indiana Plan through an Accountable Care Organization (ACO), Participating Medical Group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative. Healthy Indiana Plan Benefits/Limitations Coverage Ambulance Services Ground or air ambulance to or from a hospital for medically necessary services. Not covered when other type of transportation is available and can be used without harming Member’s health. Not covered: Ambulettes Travel to doctor’s office or clinic Travel to morgue or funeral home Behavioral Health Requires Prior Authorization Benefits for mental health and substance abuse are the same as for physical health. Chiropractic Services Spinal adjustment or manipulation is not covered. Diagnostic Services Requires Prior Authorization Not covered: Surface EMG Infertility Testing Durable Medical Equipment Prior Authorization is required Not covered: Air conditioners Humidifiers or dehumidifiers Special lighting or other environmental changes Surgical supports Corsets or other clothing items Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Inpatient services in a certified psychiatric hospital or an acute care hospital Psychological and neuropsychological testing (Requires Prior Authorization) Chiropractors may perform covered services if referred by a Member’s Primary Medical Provider. Covered: X-rays and other radiology services Ultrasounds Cardiographic, encephalographic and radioisotope tests Echocardiograms Electromyograms (EMG) Lab and pathology services Medical equipment and supplies needed to care for an illness or injury. (Formula and special food products require prior authorization.) Covered: Crutches Wheelchairs Hospital beds Oxygen equipment Version 2.2 June 1, 2014 Chapter 4: Page 37 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Healthy Indiana Plan Benefits/Limitations Coverage Emergency Room First treatment of an acute, serious illness or accidental injury; includes hospital, professional services and supplies. Copay of $3 or $25 applies and is based upon income or family status, as shown on ID card. $25 copay for all non-caretaker Members, unless they are admitted as inpatient from ER. Caretaker Members do not have to pay copay if admitted as inpatient or if ER visit is determined to be a true emergency. If cost of services is less than copay amount, member pays 20% of cost of services. Copays cannot be paid from POWER account. Family Planning Services and Supplies Not covered: Covered: Birth Control Abortion Pregnancy tests Abortifacients Sexually transmitted disease screening Infertility treatments Sterilization Home Health Care Requires Prior Authorization Not covered: Custodial Care Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Covered services (require PA): Skilled Nursing Services (60 days per benefit period) Medical/Social Services Home Health Aide Diagnostic Services Nutritional Guidance Home Infusion Therapy o Injections o Total Parenteral Nutrition o Enteral Nutrition Therapy o Antibiotic Therapy o Pain Management o Chemotherapy Version 2.2 June 1, 2014 Chapter 4: Page 38 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Healthy Indiana Plan Benefits/Limitations Coverage Hospice Hospice care may be given in the home or in a hospice facility. Requires Prior Authorization Only for Members expected to live for six months or less as determined by treating physician. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Covered services: Skilled Nursing Services Diagnostic Services Physical, speech and inhalation therapies Medical supplies, equipment and appliances Counseling Services (except bereavement counseling) Hospice facility stay Hospice prescription drugs Version 2.2 June 1, 2014 Chapter 4: Page 39 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Healthy Indiana Plan Benefits/Limitations Coverage Hospital Services – Inpatient Covered, prior authorization required: Requires Prior Authorization Not covered: Private room, unless medically necessary. Maternity Care Medical and Surgical Supplies Requires Prior Authorization Not covered: Items often found in the home, such as: Thermometers Band-Aids Petroleum Jelly Mental health and Substance Abuse Requires Prior Authorization Not covered: Residential treatment services Custodial or domiciliary care Supervised living/halfway house Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Room with two or more beds Operating, delivery and treatment rooms Prescription drugs Surgical services and supplies Anesthesia Routine pre- and post operative care and supplies Endoscopies o Colonoscopy o Laparoscopy o Bronchoscopy o Athroscopy Invasive procedures such as o Angiograms o Arteriograms o Amniocentesis o Spinal tap Diagnostic Services Therapy Services Not a covered benefit under Healthy Indiana Plan except in the case of a miscarriage / spontaneous abortion. When a miscarriage occurs before a Healthy Indiana Plan member has moved to Hoosier Healthwise, the Healthy Indiana Plan will pay the related claims. Medical and surgical supplies which serve a purely medical purpose: Syringes and Needles Oxygen Surgical dressings Medical foods Covered services: Inpatient Services Partial Hospitalization Outpatient/individual/group treatment Version 2.2 June 1, 2014 Chapter 4: Page 40 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Healthy Indiana Plan Benefits/Limitations Coverage Non-Emergency Transport Transportation to Primary Medical Provider office or other medical care Limitation: Maximum of 20 one-way trips of less than 50 miles per rolling 12-month benefit period without prior authorization Transport to pharmacies is not covered Organ Transplant Services and Procedures Requires Prior Authorization Orthotic Devices Requires Prior Authorization Not covered: Orthopedic shoes Foot support devices, such as arch supports and corrective shoes, unless they are a vital part of a leg brace. Standard elastic stockings, garter belts and other supplies not made to order and fitted (except those supplies covered under Medical and Surgical supplies). Outpatient Services/Surgery Requires Prior Authorization Outpatient services do not include mental health care/substance abuse services unless expressly stated. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan This is an Anthem Enhanced Benefit to provide non-emergent transportation for HIP Members Covered transplants: Kidney Kidney/pancreas Liver Bone Marrow Corneal Small intestine Multivisceral Heart Lung Heart/Lung Covered devices: Cervical collars Ankle foot orthosis Corsets (back and special surgical) Splints (hands and feet) Trusses and supports Slings Wristlets Built-up shoes Custom-made shoe inserts Orthotic devices may be replaced once per year by Member when medically necessary. Can be replaced a second time if the device is damaged and not cannot be repaired. Covered services include both facility and professional charges when given as an outpatient at a hospital, alternative care facility or other provider. Chemotherapy Radiation therapy Inhalation therapy Dialysis Cardiac Rehab Blood and blood products Version 2.2 June 1, 2014 Chapter 4: Page 41 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Healthy Indiana Plan Benefits/Limitations Coverage Physician Services Covered services, when given in physician’s office as medical care and consults to examine, diagnose and treat an illness or injury: Requires Prior Authorization Limit of 25 visits per benefit period for physical, occupational or speech therapy when therapy is given at a physician’s office or outpatient facility Podiatry Services Not covered: Diagnostic Surgery Surgical Services Therapy Allergy shots, testing or serum Covered services Diabetes-related foot care Routine foot care Surgery to correct o Flat feet o Hyperkeratosis o Metatarsalgia o Foot Subluxation o Tarsalgia Preventive Care/Screening Services Exempt the first $500 of services on Preventative Care Recommended List (provided by the State) each benefit period from being paid from the Member’s POWER account. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Covered Services: Routine physical/preventive exams Pelvic exams Chlamydia screening Pap test Bone density testing for women Flu shot Prostrate exam/test Mammogram Dilated eye exam for diabetic retinopathy (one per year) Routine EKG Chest X-ray Colonoscopy Lab tests Lead screenings (for Members 19 and 20 years of age only) Adult vaccines Hearing exams for Members ages 19 and 20 Version 2.2 June 1, 2014 Chapter 4: Page 42 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Healthy Indiana Plan Benefits/Limitations Coverage Prosthetic Appliances Covered, preauthorization required Requires prior authorization Not covered: Dentures, replacement teeth or structures that support teeth Dental tools Man-made heart implants Hairpieces for male pattern alopecia Wigs (except as described after cancer treatment) Skilled Nursing Facility (SNF) Requires prior authorization Up to 60 days per benefit period Aids and supports for defective parts of the body Left Ventricular/Artificial Devices when used as a bridge to a heart transplant Internal or external breast prosthesis after mastectomy Four surgical bras per benefit period Intraocular lens implant Cochlear implant Hearing aids (for Members 19 and 20 years old only) Electronic speech aid Wigs (after cancer treatment , limited to one per benefit period) Covered when medically necessary: Room with two or more beds Nursing care Physical therapy Occupational therapy Respiratory therapy Speech therapy Medical supplies and equipment Smoking Cessation Covered services: A limit of 8 hours of counseling services per rolling 12-month period Per rolling 12 month period, one 12-week course of treatment that includes: Smoking cessation products, whether prescription or overthe-counter, for up to 24 weeks per rolling 12-month period (covered under Pharmacy benefit) Therapy – PT, OT, ST Physical Therapy Each type of therapy is limited to 25 sessions per 12 month benefit period Speech Therapy Occupational Therapy Prior Authorization is required Urgent Care Center Covered Vision Care – No Vision Coverage Covered: Not covered: Medically related services and exams performed by physicians Contact lenses Frames and lenses Routine Eye Exams Covered and Non-Covered Services Pharmacy Benefits Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 43 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The State of Indiana’s Pharmacy Benefits Manager is Catamaran. The PBM administers pharmacy benefits for Hoosier Healthwise and the Healthy Indiana Plan. For more information on this topic, please go to: www.indianamedicaid.com and select Providers > Pharmacy Services. Bill charges from Pharmacy Providers to the state's PBM including: Prescription drugs approved by the United States Food and Drug Administration (FDA) Over-The-Counter (OTC) items approved by the FDA (Hoosier Healthwise) Self-injectable drugs (including insulin) Smoking cessation drugs Various equipment, such as needles, syringes, blood sugar monitors, test strips, lancets and glucose urine testing strips Please Note: Only those drugs listed on the OTC Drug Formulary are covered. You can find the OTC Drug Formulary on the Internet at: www.indianamedicaid.com. Services not covered by the pharmacy benefit include: Drugs not approved by the FDA Drugs not on the OTC Drug Formulary Drugs to help Members get pregnant Drugs used for cosmetic reasons Drugs for hair growth Drugs used to treat erectile problems Drugs used for weight loss Experimental or investigational drugs Covered and Non-Covered Services Preferred Drug List The Preferred Drug List (PDL) is located on the state’s website at: www.indianamedicaid.com and www.indianapbm.com. Click on the tab: Pharmacy Services. Covered and Non-Covered Services Preferred Drug List: Prior Authorization (PA) Forms All prior authorization forms for pharmacy can be found on the state’s website at: http://provider.indianamedicaid.com/general-provider-services/forms.aspx > Pharmacy Forms. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 44 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Covered and Non-Covered Services Mandatory Generic Drug Policy Generic substitution for brand name drugs is required by state law. Generic drugs must be provided when available. When a generic drug is available, brand name products will only be approved through written Prior Authorization, with the exception of the Narrow Therapeutic Index (NTI) medications. The following procedures are to be followed when generic prescriptions are substituted for a brand name prescription: If the prescribed brand name medication has a generic equivalent and the prescribing Provider has not requested PAB, only the FDA approved generic equivalent will be covered. If the generic equivalent medication is not medically appropriate, the Provider is required to submit a prior authorization request. If the request meets the approval criteria set forth above, the request will be approved and the brand name medication will be a covered benefit. If the request does not meet the approval criteria, then only the generic equivalent will be covered. Requests that meet the criteria are approved for one year. Please Note: Mandatory generic substitution is not applicable for brand name medications that are Narrow Therapeutic Index drugs. One of the following criteria must be met for Members to receive brand name prescriptions instead of generic equivalents: The Member must have failed adequate trials of the branded medication’s generic equivalent. The Member has an allergy or contraindication to the generically equivalent product and prescribing physician determines the brand medication is medically necessary. If a Member request for a brand name drug is denied, one of the following state-mandated denial criteria must be met: Member has not had a trial of the generic product and does not have an allergy or contraindication to the generic product. The prescribing Provider has not declared the brand name product to be medically necessary. Covered and Non-Covered Services Prior Authorization of Prescription Benefits – Full Listing For a full listing of prescriptions that require prior authorization, please see the Preferred Drug List at www.indianapbm.com. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 45 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Covered and Non-Covered Services Healthy Indiana Plan: Covered and Non-Covered Drugs With some exceptions, the Healthy Indiana Plan covers retail and mail-order prescriptions for brand name drugs, generic prescription drugs, and prescribed over-the-counter insulin. Prescription drugs excluded from Healthy Indiana Plan benefits include: Anti-Obesity drugs Brand name drugs where generic substitution is possible per Indiana Pharmacy Law Cosmetic/Hair growth Experimental or Investigational Drugs Fertility Drugs Over-The-Counter Drugs (except OTC insulin) Sexual Dysfunction drugs, oral and injectable Please Note: Non-Covered is not the same as prior authorization required. Non-Covered drugs are those that are excluded from benefit coverage. These products are not available even with prior authorization. Prior authorization criteria are set to allow for coverage if certain predetermined criteria are met. Covered and Non-Covered Services Dental Services (Hoosier Healthwise Only) The Indiana Health Coverage Programs (IHCP), which includes all state Medicaid programs such as Hoosier Healthwise, provides dental services for Members and can be reached at the following contact points: IHCP Customer Assistance Unit: 1-317-655-3240 or 1-800-577-1278 IHCP Website: www.indianamedicaid.com Primary Medical Providers in Anthem’s network perform dental screenings as part of the Initial Health Assessments (IHAs) and preventive exams for adults and children. This inspection follows guidelines established under the U.S. Preventive Task Force Guidelines. Covered and Non-Covered Services Dental Services: Screening for Dental Problems (Hoosier Healthwise) Primary Medical Providers should conduct an inspection of the teeth, gums and mouth as part of the Initial Health Assessment and refer Members to a Dentist if appropriate. Covered and Non-Covered Services Dental Services: Dental Referral Procedures (Hoosier Healthwise) Referrals to a dentist will occur, at a minimum, during the Initial Health Assessment and following each subsequent preventive care assessment, if needed. Members who have medical conditions or who are taking medication that affects the condition of the mouth or teeth should be referred on an as-needed basis. One example: Members who are immuno-compromised due to HIV or chemotherapy are at risk for developing mouth lesions that will require immediate care. Dental referral for children is a priority. Medicaid-eligible children over the age of 3 should to be referred to a dentist for preventive dental care, diagnosis and treatment of existing problems. Parents Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 46 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan needing assistance with scheduling dental appointments should be referred to Indiana's HealthWatch program, also known as the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program. Examples of covered dental services include the following: Clinical exam Intra-oral Limited oral evaluation Panoramic film Periodic oral exam Radiographs/diagnostic imaging For a complete list of covered and non-covered services see Chapter 2 of the IHCP Manual at http://provider.indianamedicaid.com/ihcp/manuals/chapter02.pdf. Covered and Non-Covered Services Dental Services: Dental Coverage for Accidents (Hoosier Healthwise) Dental services are covered under Hoosier Healthwise when a Member has an accident and it is the initial repair of an injury to the jaw, sound natural teeth, mouth or face. The following services are covered: Emergency Care Outpatient Care Physician Care Urgent Care Initial dental work to repair injuries due to an accidents should be provided within 48 hours of the injury, or as soon as possible. Covered services include all exams and treatment needed to complete the repair, such as: Lab Tests Mandibular/Maxillary Reconstruction Oral Exams Oral Surgery and Anesthesia Prosthetic Services Restorations X-Rays Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 47 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Covered and Non-Covered Services Vision Services (Hoosier Healthwise) Vision services provided by Vision Service Plan (VSP). For claims and Member questions call 1-800-6151883. Hoosier Healthwise Members are eligible for vision services. The Healthy Indiana Plan does not cover vision services. Vision services may be provided by the following: Ophthalmologists Optometrists Opticians Covered services include: One eye exam per year for Members of all ages One pair of glasses per year for Members under 21 years of age One pair of glasses every five years for Members 21 years and older (Package A) Contact lenses, when medically necessary Children may be able to have further eye tests and glasses as a part of Indiana's state program, HealthWatch. The following are typical benefits that require pre-service review: Contact lenses and tinted lenses Frames and lenses provided from a source other than the current vision volume purchase contract optical laboratory Low or subnormal vision aids Orthoptic or pleoptic training Photochromatic lenses Prosthetic eye Covered and Non-Covered Services Behavioral Health Services For information about Anthem’s Behavioral Health services, please see Chapter 5: Behavioral Health Services. Covered and Non-Covered Services Hospice Care Hospice care is covered under the Healthy Indiana Plan. Services may be provided in the home or in a hospice facility. Hospice care is not covered under the Hoosier Healthwise program. However, terminally ill Members may qualify for hospice care provided directly by the state if they disenroll from our health plan and apply directly to the state. The procedure to enter into hospice care is as follows: The hospice Provider submits a hospice election form to the Indiana Health Coverage Program's (IHCP) Prior Authorization Unit. For more information, go to their website at: http://provider.indianamedicaid.com/ihcp/manuals/hospice_benefit_manual.pdf Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 48 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The IHCP Prior Authorization Unit will then initiate the disenrollment of the Member from managed care and facilitate hospice coverage. Anthem will coordinate care for Members who are transitioning into hospice by providing any information required to complete the hospice election form for terminally ill Members desiring hospice, as described in the IHCP Hospice Provider Manual. Covered and Non-Covered Services County and State-Linked Services To ensure continuity and coordination of care for our Members, Anthem enters into agreements with locally based public health programs. Providers are responsible for notifying Anthem’s Case Management department when a referral is made to one of the agencies listed below. Case Management Phone: Case Management Fax: 1-866-408-7187 1-866-387-2959 This notification ensures that case manager nurses and social workers can follow up with Members to coordinate their care. It also ensures that Members receive all necessary services while keeping the Provider informed. Covered and Non-Covered Services State Services and Programs The following information identifies state services and programs, and the services these state programs provide upon referral. Indiana Division of Mental Health and Addiction (DMHA): Provides treatment for re-integration into the community. DMHA Website: www.in.gov/fssa/dmha/4521.htm Indiana Division of Disability & Rehabilitation Services: Provides independence through in-home services, supported employment, independent living, nutrition assistance, services for Members with hearing loss, blindness or visual impairment, as well as social security disability eligibility. DDRS Website: www.in.gov/fssa/2328.htm Children’s Special Health Care Services (CSHCS): CSHCS is a non-Medicaid program administered by the Indiana State Department of Health (ISDH) that provides financial assistance for needed medical treatment to children with serious and chronic medical conditions to reduce complications and promote maximum quality of life. CSHCS Website: www.in.gov/isdh/19613.htm Covered and Non-Covered Services Essential Public Health Services Anthem collaborates with public health entities in all service areas to ensure essential public health services for Members. Services include: Coordination and follow-up of suspected or confirmed cases of childhood lead exposure Ensuring appropriate public health reporting (communicable diseases and/or diseases preventable by immunization) Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 49 Chapter 4: Covered and Non-Covered Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Investigation, evaluation and preventive treatment of persons with whom the Member has come into contact Notification and referral of communicable disease outbreaks involving Members Referral for tuberculosis and/or sexually transmitted infections or HIV contact Referral for Women, Infants, and Children (WIC) services and information sharing Covered and Non-Covered Services Directly Observed Therapy Tuberculosis (TB) has reemerged as an important public health problem at the same time as drug resistance to the disease continues to rise. In large part, this resistance can be traced to poor compliance with medical regimens. In Directly Observed Therapy (DOT), the Member receives assistance in taking medications prescribed to treat TB. Members with TB showing evidence of poor compliance should be referred to the Local Health Department (LHD) for DOT services. Covered and Non-Covered Services Reportable Diseases By state mandate, Providers must report communicable diseases and conditions to local health departments. Anthem’s Providers are to comply with all state laws in the reporting of communicable diseases and conditions. Timely reporting is vital to minimize outbreaks and prevalence. Covered and Non-Covered Services WIC Referrals The Women, Infants and Children (WIC) program provides healthy food to pregnant women and mothers of young children. Providers have the following responsibilities for Women, Infants and Children (WIC) program referrals: Complete the WIC Program Referral Form that documents the following information: Anthropometric data: height, current weight, pregravid weight Any current medical conditions Biochemical data: hemoglobin, hematocrit Expected Date of Delivery (EDD) Provide Member with completed referral form to be presented at the local WIC agency The Indiana WIC Program Referral Form is located on the state's website at www.in.gov/isdh/24777.htm. Indiana WIC Phone: 1-800-522-0874 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 50 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 5: BEHAVIORAL HEALTH SERVICES Hoosier Healthwise: Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan: Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Behavioral Health Services Overview Behavioral Health Services are an integral part of health care management at Anthem Blue Cross and Blue Shield (Anthem). Our mission is to coordinate the physical and behavioral health care of Members by offering a wide range of targeted interventions, education and enhanced access to care to ensure improved outcomes and quality of life for members. Anthem works collaboratively with hospitals, group practices and independent behavioral health care providers, as well as community agencies and Indiana’s Community Mental Health Centers and other resources to successfully meet the needs of members with mental health, substance use and intellectual and developmental disabilities. Behavioral Health Services Goals The goals of Anthem’s Behavioral Health program are to: Ensure and expand service accessibility to eligible members Promote the integration of the management and delivery of physical and behavioral health services Achieve quality initiatives including those related to HEDIS, NCQA and Indiana OMMP performance requirements Work with Members, Providers and community supports to provide recovery tools and create an environment that supports Members’ progress toward their recovery goals Ensure utilization of the most appropriate, least restrictive, medical and behavioral health care in the right place at the right time Behavioral Health Services Objectives The objectives of the Anthem Behavioral Health program are to: Promote continuity and coordination of care among physical and behavioral health care practitioners Enhance member satisfaction by implementing individualized and holistic support and care plans that allow Members to achieve their recovery goals Provide Member education on treatment options and pathways toward recovery Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 51 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Provide high quality case management and care coordination services that identify Member needs and address them in a personal and holistic manner Work with care providers to ensure the provision of medically necessary and appropriate care and services, including inpatient care, alternative care settings, and outpatient care at the least restrictive level Enhance Provider satisfaction and success through collaborative and supportive relationships built on mutually agreed upon goals, outcomes and incentives Promote collaboration between all health care partners to achieve recovery goals through education, technological support and the promotion of recovery ideals Use evidence-based guidelines and clinical criteria and promote their use in the Provider community Maintain compliance and accreditation standards with local, state and federal requirements Anthem-contracted Providers deliver behavioral health and substance use disorder services in accordance with best practice guidelines, rules and regulations, and policies and procedures set forth by the State of Indiana. Behavioral Health Services Guiding Principles of Anthem’s Behavioral Health Program Recovery is a Member-driven process in which people find their paths to work, learn and participate fully in their communities Resiliency is the ability to live a fulfilling and productive life despite the continued presence of a disability. Physical and behavioral health services are rendered in a manner that allows the achievement of recovery for Members experiencing mental illness and substance use disorders. Treatment supports the development of resiliency for those facing mental illness, serious emotional disturbance and/or substance use disorder issues. The Substance Abuse and Mental Health Services Administration (SAMHSA) released a consensus statement on mental health recovery reflecting the desire that all behavioral health services be delivered in a manner that promotes individual recovery and builds resiliency. The ten fundamental components of recovery identified by SAMHSA are: Self-direction: Members lead, control and determine their own paths of recovery by optimizing autonomy, independence and control of resources to achieve a self-determined life. Individualized care: There are multiple pathways to recovery based on an individual’s unique strengths and resiliency, as well as his or her needs, preferences and experiences including past trauma and cultural background. Empowerment: Members have the authority to choose from a range of options and to participate in all decisions, including the allocation of resources, which will affect their lives and are educated and supported in so doing. Holistic: Recovery embraces all aspects of life, including housing, employment, education, mental and health care treatment and services, complementary and naturalistic services (e.g., recreational services, libraries, museums, etc.), addictions treatment, spirituality, creativity, social networks, community participation and family supports as determined by the person. Nonlinear: Recovery is not a step-by-step process but one based on continual growth, occasional setbacks and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables the consumer to move on to fully engage in the work of recovery. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 52 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Strengths-based: Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities and inherent worth of individuals. Peer support: Mutual support including the sharing of experiential knowledge, skills and social learning plays an invaluable role in recovery. Respect: Community, systems and societal acceptance and appreciation of consumers — including protecting their rights and eliminating discrimination and stigma — are crucial to achieve recovery. Responsibility: Members have a personal responsibility for their own self-care and journeys of recovery. Hope: Recovery provides the essential and motivating message of a better future — that people can and do overcome the obstacles that confront them. Hope is internalized but can be fostered by peers, family, friends, Providers and others. Hope is the catalyst of the recovery process. Resiliency is the ability of an individual or family to cope and adapt to the challenges and changes brought on by distress or disability. Becoming resilient is a dynamic developmental process that requires patience and effort to pursue steps that enhance positive responses to adverse circumstances. Accepting and managing one’s life in a manner that displays optimism for personal successes manifested by traits of self-efficacy and high self-esteem is achieved by building resiliency. Resilience is learned and developed. Behavioral Health Services Systems of Care Services provided to people with serious emotional disturbances and their families are best delivered based on the System of Care Values and Principles that are endorsed by SAMHSA and the Center for Mental Health Services (CMHS). Services should be: Person-centered and family-focused with the needs of the person and family dictating the types and mix of services provided. Community-based with the focus of services as well as management and decision making responsibility resting at the community level. Culturally competent with agencies, programs, and services that are responsive to the cultural, racial, and ethnic differences of the populations they serve. Comprehensive, covering an array of services that address physical, emotional, social, educational and cultural needs. Personalized as evidenced by an individualized service plan formulated to meet unique needs and potential. Delivered in the least restrictive, most normative environment that is clinically appropriate. Integrated and coordinated between agencies and include mechanisms for planning, developing and coordinating services inclusive of case management or similar mechanisms to ensure that multiple services are delivered in a coordinated, therapeutic manner and adapted in accordance with the changing needs of the person and their family. Delivered without regard to race, religion, national origin, sex, physical disability or other characteristics. Oriented to recovery, providing services that are flexible and evolve over time. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 53 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Behavioral Health Services Coordination of Behavioral Health and Physical Health Treatment Key elements of the model for coordinated and integrated physical and behavioral health services include: Ongoing communication and coordination between Primary Medical Providers and specialty providers, including behavioral health (mental health and substance use) providers. Screening by Primary Medical Providers for mental health, substance use and co-occurring disorders. Discussions by behavioral health Provider of physical health conditions. Referrals to Primary Medical Providers or specialty Providers, including behavioral health providers, for assessment and/or treatment for consumers with co-occurring disorders and/or any known or suspected and untreated physical health disorders. Development of patient-centered treatment plans Involving members as well as caregivers and family members when appropriate. Case management and disease management programs to support the coordination and integration of care between Providers. Fostering a culture of collaboration and cooperation helps sustain a seamless continuum of care between physical and behavioral health and positively impacts Member outcomes. To maintain continuity of care, patient safety and Member well-being, communication between behavioral health and physical care providers is critical, especially for Members with co-morbidities receiving pharmacological therapy. Behavioral Health Services Provider Roles and Responsibilities At Anthem, our behavioral health care benefit is fully integrated with the rest of our health care programs. This coordination of healthcare resources requires certain roles and responsibilities for behavioral health Providers, including the following: Participate in the care management and coordination process for each Anthem Member under your care. Seek Prior Authorization for all services that require it. Provide Anthem and the Member's Primary Medical Provider with a summary of the Member's initial assessment, primary and secondary diagnosis and prescribed medications if the Member is at risk for hospitalization. This information must be provided within 24 hours after the initial treatment session. Provide, at a minimum, a summary of the findings from the Member's initial visit to Anthem and the Primary Medical Provider. This must be provided within 5 calendar days of the visit for Members not at risk for hospitalization. This notification must include the behavioral health Provider's contact information, visit date, presenting problem, diagnosis and a list of any medications prescribed. Notify Anthem and the Member's Primary Medical Provider of any significant changes in the Member's status and/or change in the level of care. Ensure that Members receiving inpatient psychiatric services are scheduled for an outpatient followup and/or continuing treatment prior to discharge. This treatment must be provided within 7 calendar days from the date of the Member's discharge. Offer hours of operation that are no less than the hours of operation offered to commercial Members. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 54 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Encourage Members to consent to the sharing of substance abuse treatment information Behavioral Health Services Transition after Acute Psychiatric Care To assist in the transition of Anthem Members from an acute psychiatric facility to home or an alternative setting, Anthem recommends scheduling a transition appointment. A licensed behavioral health practitioner should conduct this therapy session, which must take place after discharge, but before the Member actually leaves the facility. The process is as follows: The acute care facility obtains authorization for the transition appointment by working with Anthem's care manager. The care manager provides a Transitions Program Appointment Authorization Worksheet. The licensed Provider completes, signs and faxes the worksheet to the utilization review team following the appointment. (The appropriate fax number is listed at the top of the worksheet.) Anthem will authorize payment. For more information, please call Utilization Management: Hoosier Healthwise: 1-866-408-7187 Healthy Indiana Plan: 1-866-398-1922 Behavioral Health Services Provider Success We believe the success of Providers is necessary to achieve our goals. We are committed to supporting and working with qualified Providers to ensure that we jointly meet quality and recovery goals. Our commitment includes: Improving communication of the clinical aspects of behavioral health care to improve outcomes and recovery Supporting providers in delivering integrated, coordinated physical and behavioral health services to meet the needs of the whole person Simplifying precertification rules, referrals, claims and payment processes to help Providers reduce administrative time and focus on the needs of members Behavioral Health Services Health Plan Clinical Staff All clinical staff are licensed and have at least four years of prior clinical experience. Our Medical Director is board certified in psychiatry and licensed in the State of Indiana. Our highly trained and experienced team of clinical care managers, case managers and support staff provide high quality care management and care coordination services to our Members and strive to work collaboratively with all Providers. Behavioral Health Services Coordination of Physical and Behavioral Health Services As a network Provider, you are required to notify a Member’s Primary Medical Provider when a Member first enters behavioral health care and anytime there is a significant change in care, treatment, Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 55 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan medications or need for medical services. You must secure the necessary release of information from the Member or the Member’s legal guardian. You should provide initial and summary reports to the Primary Medical Provider on at least a quarterly basis. The minimum elements to include are: Patient demographics Date of initial or most recent behavioral health evaluation Recommendation to see Primary Medical Provider, if medical condition identified or need for evaluation by a medical practitioner has been determined for the Member (e.g., EPSDT screen, complaint of physical ailments) Diagnosis and/or presenting behavioral health problem(s) Prescribed medication(s) Behavioral health clinician’s name and contact information Behavioral Health Services Case Management Anthem’s behavioral health case management programs are designed to improve Member health outcomes by integrating with our medical care programs and making reliable and proven protocols available to Providers. We view case management as a continuum of services and supports that are matched on an individualized basis to the needs of the Member. Members who are identified as at-risk for hospitalization due to behavioral health or substance use disorders are offered ongoing case management support. In addition, Members who are discharged from inpatient stays are provided case management support for a minimum of 180 days post discharge. Anthem provides clinical teams staffed with Indiana-based behavioral health and medical case managers working in close collaboration with community and Provider-based case managers. The main functions of the Anthem behavioral health case managers include, but are not limited to: Use health risk appraisal data gathered by Anthem from Members upon enrollment to identify Members who will benefit from engagement in individualized care coordination and case management. Use “trigger report data” based upon medical and behavioral health claims to identify Members at risk. Consult and collaborate with our medical case managers and disease management clinicians regarding Members who present with comorbid conditions. **Comorbid is either the presence of one or more disorders (or diseases) in addition to a primary disease or disorder, or the effect of such additional disorders or diseases. Refer Members to Provider-based case management for ongoing intensive case management and then continue involvement with the Member and the Provider to coordinate care, when needed, among different agencies, medical providers, etc. Work directly with the Member and Provider based upon the severity of the Member’s condition. Document all actions taken and outcomes achieved for Members in Anthem's information system to ensure accurate and complete reporting. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 56 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Behavioral Health Services Member Records and Treatment Planning: Comprehensive Assessment Member records must meet the following standards and contain the following elements, if applicable, to permit effective service provision and quality reviews: Information related to the provision of appropriate services to a Member must be included in his or her record with documentation in a prominent place whether there is an executed declaration for mental health treatment. Providers must submit a comprehensive assessment that provides a description of the Member’s physical and mental health status at the time of admission to services. It should include: Psychiatric and psychosocial assessment including: o Description of the presenting problem o Psychiatric history and history of the Member’s response to crisis situations o Psychiatric symptoms o Multi-axial diagnosis using the most current edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) o Mental status exam Medical assessment including: o Screening for medical problems o Medical history o Present medications o Medication history Substance use assessment that includes: o Frequently used over-the-counter medications o Current and historical usage of alcohol and other drugs reflecting impact of substance use in the domains of the community functioning assessment o History of prior alcohol and drug treatment episodes and their effectiveness o History of alcohol and drug use Community functioning assessment or an assessment of the Member’s functioning in the following domains: o Living arrangements, daily activities (vocational/educational) o Social support o Financial o Leisure/recreational o Physical health o Emotional/behavioral health o An assessment of the Member’s strengths, current life status, personal goals and needs Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 57 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Behavioral Health Services Member Records and Treatment Planning: Personalized Support and Care Plan A patient-centered support and care plan based on the psychiatric, medical substance use and community functioning assessments found in the initial comprehensive assessment must be completed for any Member who receives behavioral health services. There must be documentation in every case that the Member and, as appropriate, his or her family members, caregivers or legal guardian, participated in the development and subsequent reviews of the treatment plan. The support and care plan must be completed within the first 14 days of admission to behavioral health services and updated every 180 days, or more frequently as necessary based on the Member’s progress toward goals or a significant change in psychiatric symptoms, medical condition and/or community functioning. There must be a signed release of information to provide information to the member Primary Medical Provider or evidence that the Member refused to provide a signature. There must be documentation that referral to appropriate medical or social support professionals have been made. A Provider who discovers a gap in care is responsible to help the Member get that gap in care fulfilled and documentation should reflect the action taken in this regard. For Providers of multiple services, one comprehensive treatment/care/support plan is acceptable as long as at least one goal is written, and updated as appropriate, for each of the different services that are being provided to the Member. The treatment/support/care plan must contain the following elements: Identified problem(s) for which the Member is seeking treatment Member goals related to each problem(s) identified, written in Member-friendly language Measurable objectives to address the goals identified Target dates for completion of objectives Responsible parties for each objective Specific measurable action steps to accomplish each objective Individualized steps for prevention and/or resolution of crisis, which includes identification of crisis triggers (situations, signs and increased symptoms); active steps or self-help methods to prevent, de-escalate or defuse crisis situations; names and phone numbers of contacts who can assist the Member in resolving crisis; and the Member’s preferred treatment options, to include psychopharmacology, in the event of a mental health crisis Actions agreed to be taken when progress toward goals is less than originally planned by the Member and Provider Signatures of the Member as well as family members, caregivers or legal guardian as appropriate. Behavioral Health Services Member Records and Treatment Planning: Progress Notes Progress Notes must document the status of the goals and objectives indicated on the treatment plans and should include: Correspondence concerning the Member’s treatment and signed and dated notations of telephone calls concerning the Member’s treatment Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 58 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Indication of active follow up actions for referrals given to the Member and actions to fill gaps in care A brief discharge summary must be completed within 15 calendar days following discharge from services or death Discharge summaries for psychiatric hospital and residential treatment facility admissions that occur while the member is receiving behavioral health services Treatment and care plan and progress notes should be signed by the supervising physician Behavioral Health Services Psychotropic Medications Prescribing Providers must inform all Members considered for prescription of psychotropic medications of the benefits, risks and side effects of the medication, alternate medications and other forms of treatment. If obesity is also a problem, the medical record needs to reflect that a healthy diet and exercise plan has been prepared and given to the Member or if appropriate a referral to a nutritionist or obesity medical professional. If diabetes is a problem, the medical record needs to reflect a discussion with the member about their condition and their treating provider should be identified in the documentation and coordination efforts with that provider should be indicated as well. The medical record is expected to reflect such conversations as having occurred. The medical record is expected to indicate the prescription data has been shared with the Member’s Primary Medical Provider. Members on psychotropic medications may be at increased risk for various disorders. As such it is expected that providers are knowledgeable about side-effects and risks of medications and regularly inquire about and seek for any side-effects from medications. This especially includes: Follow-up to inquire about suicidality or self-harm in children placed on anti-depressant medications as per Food and Drug Administration and American Psychiatric Association guidelines Regular and frequent weight checks and measurement of abdominal girth especially for those on antipsychotics or mood stabilizers Glucose tolerance test or hemoglobin A-1C tests especially for those members on antipsychotics or mood stabilizers Triglyceride and cholesterol checks especially for those members on antipsychotics and mood stabilizers ECG checks for members placed on medications with risk for significant QT-prolongation. Ongoing checks for movement disorders related to antipsychotic use and psychotic disorders. Guidelines for such testing and follow-up are provided by the American Psychiatric Association among others. Summary guidelines are referenced in our Clinical Practice Guidelines located on our website at www.anthem.com. While the prescriber is not expected to personally conduct all of these tests, the prescriber is expected to ensure that these tests occur where indicated and to initiate appropriate interventions to address any adverse results. These tests and the interventions must be documented in the Member’s medical record. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 59 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Behavioral Health Services Utilization Management As a corporation and as individuals Utilization Management (UM) Decisions are governed by the following statements: UM-decision making is based only on appropriateness of care and service and existence of coverage. Practitioners or other individuals are not specifically reward for issuing denial of coverage care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support, or tend to support, denial of benefits. Financial incentives for UM decision-makers do not encourage decisions that result in underutilization or create barriers to care and service. Behavioral Health Services Timeliness of Decisions on Requests for Authorization Behavioral Health 1. 2. 3. 4. Urgent, Pre-Service Requests: Within 72 hours of request Urgent Concurrent Requests: Within 24 hours of request Routine, Non-Urgent Requests: 14 days Retrospective Review Requests: Within 30 days of request Behavioral Health Services Access to Care Standards This grid outlines standards for timely and appropriate access to quality behavioral health care. Behavioral Health 1. Emergent: Immediately 2. Emergent, Non-Life-Threatening/Crisis Stabilization; Within 24 hours of request 3. Urgent: Within 48 hours of referral / request 4. Routine Outpatient: Within 10 days of request 5. Outpatient following discharge from an IP Hospital: Within 7 days of discharge Definitions Emergent: Treatment is considered to be an on-demand service and does not require precertification. Members are asked to go directly to emergency rooms for services if they are either unsafe or their conditions are deteriorating. Urgent: Means a service need that is not emergent and can be met by providing an assessment and services within 48 hours of the initial contact. If the Member is pregnant and has substance use problems she is to be placed in the urgent category. Routine: Means a service need that is not urgent and can be met by receiving treatment within 10 days of the assessment without resultant deterioration in the individual's functioning or worsening of his or her condition. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 60 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Behavioral Health Services How to Provide Notification or Request Preauthorization You may request preauthorization for non-routine outpatient mental health services that require prior preauthorization via phone by calling 1-866-408-7187 24 hours a day, seven days a week, 365 days a year. Please be prepared to provide clinical information in support of the request at the time of the call. You may request preauthorization via fax for certain levels of care. Fax forms are located on the Provider Resources page of our website at www.anthem.com. For information on how to access the Provider Resources page, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. The fax numbers to use when providing notification or requesting prior authorization for behavioral health services are: Outpatient requests: 1-877-276-5036 Note: All requests for precertification for psychological and neuropsychological testing should be submitted via fax at 1-877-276-5036 Psychological and neurological testing request forms can also be mailed to: Behavioral Health Department Indiana Medicaid P.O. Box 6144 Indianapolis, IN 46204 All facility-based behavioral health and substance use services require prior authorization. Behavioral Health Services Necessity Determination and Peer Review When a Provider requests initial or continued precertification for a covered service, our Utilization Managers obtain necessary clinical information and review it to determine if the request meets applicable medical necessity criteria. If the information submitted does not appear to meet such criteria, the Utilization Manager submits the information for review by the Medical Director, or other appropriate practitioner, as part of the peer review process. The reviewer, or the requesting Provider, may initiate a peer-to-peer conversation to discuss the relevant clinical information with the clinician working with the member. If an adverse decision is made by the reviewer without such a peer-to-peer conversation having taken place (as may occur when the Provider is unavailable for review), the Provider may request such a conversation. In this case, we will make a Medical Director, or other appropriate practitioner, available to discuss the case with the requesting Provider. This conversation may result in the decision being upheld or changed. Members requesting Providers and applicable facilities are notified of any adverse decision within notification timeframes that are based on the type of care requested and in conformance with regulatory and accreditation requirements. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 61 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Behavioral Health Services Non-Medical Necessity Adverse Decisions (Administrative Adverse Decision) If you received an Administrative Adverse Determination and think that this decision was in error, please see Chapter 13: Grievances and Appeals for information and instructions on appeals, grievances and payment disputes. Behavioral Health Services Provider Appeals, Grievances and Payment Disputes If you did not receive a precertification for a requested service and think that this decision was in error, please see Chapter 13: Grievances and Appeals for information and instructions on appeals, grievances and payment disputes. Behavioral Health Services Avoiding an Adverse Decision Most administrative adverse decisions result from non-adherence to, or a misunderstanding of, utilization management policies. Familiarizing yourself and your staff with notification and precertification policies and acting to meet those policies can eliminate the majority of these decisions. Other administrative adverse decisions result from misinformation about the Member’s status or benefits. Such information is readily available from us by calling 1-866-408-7187. Adverse decisions of a medical nature are rare. Such adverse decisions usually involve a failure of the clinical information to meet evidenced-based national guidelines. We are committed to working with all Providers to ensure that such guidelines are understood and easily identifiable for Providers. Peer-topeer conversations (between a Medical Director and the Provider clinicians) are one way to ensure the completeness and accuracy of the clinical information. Medical record reviews are another way to ensure that clinical information is complete and accurate. Providers who can appropriately respond in a timely fashion to peer-peer and medical record requests are less likely to encounter dissatisfaction with the utilization management process. We are committed to ensuring a process that is quick and easy and will work with participating Providers to ensure a mutually satisfying process. Behavioral Health Services Clinical Practice Guidelines All providers have access to evidence-based clinical practice guidelines for a variety of behavioral health disorders commonly seen in primary care including Attention deficit hyperactivity disorder, bipolar disorder for children and adults, major depressive disorder, schizophrenia and substance use disorders. These clinical practice guidelines are located online at www.anthem.com. Behavioral Health Services Emergency Behavioral Health Services Primary Medical Providers should immediately refer any Member who is in crisis or who is a threat to self or others for emergency care. An emergency referral for behavioral health services does not require prior authorization or pre-service review. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 62 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Behavioral Health Services Behavioral Health Services: Referral Criteria to Behavioral Health Specialists Primary Medical Providers may treat Members with situational behavioral health disorders, the most common of which are depression and anxiety. For Members whose behavioral health does not respond to treatment in a primary care setting, contact us for referral and authorization information regarding assessment and ongoing services at: Hoosier Healthwise Behavioral Health Services: 1-866-408-7187 Healthy Indiana Plan Behavioral Health Services: 1-866-398-1922 Primary Medical Providers are required to refer Members who are experiencing acute symptoms of a chronic behavioral health disorder, exhibiting an acute onset of symptoms, or are in a crisis state. Please refer to the Benefits Matrix for the range of services covered. Primary Medical Providers are also required to make referrals for Members whose symptoms of anxiety and mild depression persist or become worse. Any Member suspected of developing toxicities to medications that have been prescribed by a psychiatrist will need to be referred back to the behavioral health system for observation and monitoring of medications. Primary Medical Providers should refer any Member with the following established diagnosis or suspected onset of symptoms indicative of these disorders to a behavioral health Specialist: Adjustment Disorder Behavioral Disorders of Children and Adolescents Bipolar Disorders Eating Disorders Multiple Diagnosis Psychoses, Involutional, Depressive Schizophrenia Unipolar Depression Behavioral Health Services Behavioral Health Services: Criteria for Provider Type Selection Psychiatrist Referrals The following criteria should be met before referring a Member to a psychiatrist: Member is taking psychoactive medication Member is referred by Primary Medical Provider or under Primary Medical Provider treatment for relevant problem Member, if a child, had prior treatment for same problem without medication and problem is severe or disabling in some area of life Problem is cognitive and Member has had previous inpatient or day treatment Problem is cognitive and overall dysfunction is severe or disabling Problem recurrent or greater than six months and Member has prior treatment Problem recurrent of greater than six months and dysfunction severe or disabling in any area of functioning Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 63 Chapter 5: Behavioral Health Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Problem is somatic and referral was not from Primary Medical Provider Problem is somatic, Member is under Primary Medical Provider care, and problem is severe or disabling in some area of functioning Referrals to a Psychologist or Licensed Clinical Social Worker (LCSW) The following criteria should be met before referring a Member to a psychologist or Licensed Clinical Social Worker: Identifiable stressor is present Member is not taking psycho-actives Member not referred by Primary Medical Provider, not under Primary Medical Provider treatment for relevant problem Problem not recurrent, not greater than six months duration Problem not severe or disabling in any area of functioning Behavioral Health Self-Referrals: Members may self-refer to any behavioral health care Provider in Anthem’s network or to an Indiana Health Coverage Program (IHCP) psychiatrist. If the Member is unable or unwilling to access timely services through community Providers, call Anthem’s Customer Care Center for assistance. Behavioral Health Services Links to Forms, Guidelines and Screening Tools Mental Health and Substance Use Covered Services: www.anthem.com Services Requiring Precertification: www.anthem.com Non-covered diagnoses: www.anthem.com Screening tools for Primary Medical Providers and behavioral health providers: www.anthem.com Our Clinical Practice Guidelines (CPGs) Summary guidelines: www.anthem.com Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 4: Page 64 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 6: MEMBER ELIGIBILITY Hoosier Healthwise: Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan: Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Member Eligibility Overview Given the increasing complexities of health care administration, widespread potential for fraud and abuse, and constant fluctuations in program membership, Providers need to be vigilant about Member eligibility. That may mean taking extra steps to verify that any patient treated by Anthem Providers is, in fact, a currently enrolled Anthem Member. To prevent fraud and abuse, Providers should confirm the identity of the person presenting the ID card. Providers must also verify a Member’s eligibility before services are delivered. Because eligibility can change, it should be verified at every visit. Remember that claims submitted for services rendered to non-eligible Members will not be eligible for payment. Member Eligibility How to Verify Member Eligibility Providers can verify Member eligibility by doing any one of the following: Log in to www.Availity.com Swipe the Member's ID card through a Point of Service (POS) device (HIP Members) or enter the Member ID (Note HIP Members have an Anthem ID in addition to their Medicaid Recipient ID (RID)): Hoosier Healthwise Members have an ID card issued by the state. Healthy Indiana Plan Members have an ID card issued by Anthem. Use the Indiana Health Coverage Program (IHCP) Automated Voice Response (AVR) system at: 1-800-738-6770 or 1-317-692-0819 (for Providers in the 317 Area Code) Enter the Member’s RID Log in to Indiana’s secure website, Web interChange, at: https://interchange.indianamedicaid.com/Administrative/logon.aspx Enter the Member’s RID To apply for a Web interChange user ID and password: 1. Complete the Web interChange administrator access request form available at: https://interchange.indianamedicaid.com/Administrative/logon.aspx 2. Print the form and mail it to the address on the form. Providers will be notified by e-mail when the application is approved. Please Note: Indiana's Family and Social Services Administration (FSSA) will provide eligibility status, but will not provide Primary Medical Provider assignment during enrollment. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 6: Page 65 Chapter 6: Member Eligibility Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Member Eligibility Pharmacy Electronic Member Eligibility To confirm eligibility for Hoosier Healthwise and the Healthy Indiana Plan, Pharmacists and pharmacy staff may call HP Enterprise Services 24 hours a day, 7 days a week at 1-800-457-4584. Member Eligibility Member ID Cards Following enrollment, eligible enrollees will receive a Member ID Card. Hoosier Healthwise Members will receive only a state-issued ID card, the Hoosier Health Card. Healthy Indiana Plan Members will receive only an Anthem-issued ID card, the Anthem Member ID Card: Hoosier Healthwise: Healthy Indiana Plan: Anthem Member ID Card Hoosier Health Card Hoosier Health Card The Hoosier Health Card, issued by the state, authorizes medical services for Hoosier Healthwise Members through their managed care plan. The card is a permanent, plastic ID card that Members retain during their lifetime. The card includes the following Member information: Name Sex Date of Birth Recipient Identification Number (RID) Please Note: The Recipient Identification (RID) number is what Providers should use to verify Member eligibility. The Hoosier Health Card is used for identification purposes only. Please Note: Healthy Indiana Plan Members do not receive a Hoosier Health Card. Anthem Healthy Indiana Plan Card Following enrollment, a Healthy Indiana Plan Member receives an Anthem Healthy Indiana Plan Card that must be presented at each Provider or facility visit. Anthem’s Healthy Indiana Plan Card contains the following Member information: Name Anthem Member ID Number ER Co-pay Responsibility Name and Phone Number of Member’s Primary Medical Physician Group Number and Plan Code RXBIN Recipient Identification Number (RID) Telephone Numbers for 24/7 NurseLine, Member Services, Transportation, Provider Services If a card is lost, Members may receive replacement cards upon request through our Customer Care Center. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 6: Page 66 Chapter 6: Member Eligibility Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Please Note: At each Member visit, Providers must ask to see the Member’s ID card. This verification should be done before rendering services and before submission of claims to Anthem. Member Eligibility Presumptive Eligibility Presumptive Eligibility (PE) is short-term coverage of outpatient prenatal care to women while a Medicaid application for membership in Hoosier Healthwise is pending. The Presumptive Eligibility for Pregnant Women program enables eligible women to receive prenatal care early in their pregnancies. Low-income pregnant women are determined presumptively eligible through an application process. For questions about Presumptive Eligibility, contact Indiana's Family and Social Services Administration Customer Service: FSSA Customer Service: 1-317-655-3240 E-Mail: [email protected] http://provider.indianamedicaid.com/about-indiana-medicaid/member-programs/specialprograms/qualified-provider-presumptive-eligibility-(pe).aspx Member Eligibility Right Choices Program (RCP) The Right Choices Program (RCP) is designed as a safeguard against unnecessary or inappropriate use of Medicaid benefits by Members who use Indiana Health Coverage Programs (IHCP) services more extensively than their peers. The goal is to help improve our Members' care by reducing inappropriate use of pharmacy and other health services, which could harm the Member and create unnecessary and wasteful program expenditures. Member Eligibility Primary Lock-In Provider Responsibilities in the RCP By providing a medical “home,” the Primary Lock-In Provider is better able to manage a Member’s care and coordinate services. By utilizing the Right Choices Program, a single Provider is made aware of all of the Member’s treatments and medications. This reduces the potential for contradictory treatments and adverse health outcomes. Providers will be notified of lock-in status through a Lock-in Physician Notification Letter generated via the state's Web interChange. The Primary Medical Provider is required to use referrals if the RCP Member requires evaluation or treatment by a Specialist or another Provider. The purpose of the referral is to assure that the Primary Medical Provider has authorized the visit to the referral Provider. The referral must be sent to Anthem's RCP Administrator to assure that claims from referral Providers will be processed for payment. Referral Providers who treat lock-in Members are also responsible for checking Medicaid eligibility and should not treat the Member if the Primary Medical Provider’s referral has not been obtained. The Member must be notified in advance of receiving any service that is not covered by Medicaid. The Member must sign a waiver acknowledging that he or she will be billed for the non-covered service before receiving the service. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 6: Page 67 Chapter 6: Member Eligibility Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan If a Member pays cash (and a Provider receives cash) for any Medicaid-covered service, it is considered a fraudulent activity by both parties. If the referral Provider wants to refer the Member to a third physician, the Primary Medical Provider must also sign the referral and send it to Anthem's RCP Administrator before the third Provider will be added to the Member’s lock-in list. Additionally, each referral must include the following information: Indiana Health Coverage Program Member’s name Indiana Health Coverage Program Member’s RID (Recipient Identification) First and last name of the referral Provider (the second physician) First and last name of the referral Provider (the third physician) New Provider’s National Provider Identifier (NPI) Date of the referral The Primary Medical Provider’s manual or electronic signature (office staff signatures are unacceptable) Date(s) of service for which the referral is valid Please Note: If no time period is specified on the referral, it will be approved for up to one year depending on the type of Provider being added. The start date of the referral will be the date indicated on the referral unless an alternate start date is specified by the Primary Medical Provider. A second hospital or pharmacy may be added for the dates of service only. Exceptions: If the Primary Medical Provider has not sent a referral for the Member to Anthem's RCP Administrator, and the Primary Medical Provider is not available to write a referral, temporary Provider coverage may be approved by the RCP Administrator. Referrals are not required for Medicaid services covered directly by the state, unless prescriptions related to those services are going to be dispensed from a pharmacy. The services that do not require referrals include the following: Behavioral Health Dental Ophthalmology/optometry care Podiatry Waiver Services If prescriptions are needed from Providers who render services directly from the state, the following options are available: The Primary Medical Provider may write the prescription for the referral Provider The rendering Provider may send the Primary Medical Provider’s referral to Anthem's RCP Administrator for that prescription's addition to the Member’s lock-in list Retroactive referrals may be sent in cases where the Primary Medical Provider approves services provided on the date of service but failed to send the referral to Anthem's RCP Administrator at that time. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 6: Page 68 Chapter 6: Member Eligibility Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Retroactive referrals may be accepted if the start date of the retroactive referral is within the claims filing limit. The retroactive referral may be valid for up to one year from the retroactive start date. The Primary Medical Provider’s medical records for the Member should indicate on or near the date of service that the referred service was approved. The Primary Medical Provider is not required to approve any service for which he or she had no knowledge on the date of service. The following circumstances may be eligible for a retroactive referral: Auto-assigned Member lives in an underserved area and is unable to select a Primary Medical Provider from that area Death of Primary Medical Provider Newly-transitioned Members into the program (i.e. wards and foster children) who are in need of treatment within the first 60 days of enrollment Primary Medical Provider change is still pending after a previously auto-assigned Member has selected a new Primary Medical Provider Primary Medical Provider moves out of the region and fails to notify the program Urgent, emergent or ongoing issues (i.e. dialysis or ER admission) where the Member is unable to access necessary services and the assigned Primary Medical Provider is unwilling or unable to provide services or the appropriate referral Termination of RCP Member Care: Providers may opt to terminate a Member’s care for specific reasons outlined in the Provider’s internal office policies and the state's RCP Provider Manual, available at the state's Medicaid website: www.indianamedicaid.com. Reasons for termination include non-compliance with treatment recommendations or abusiveness to office staff. The following are the requirements for termination of a RCP Member: The Provider is required to deliver a letter to the Member, with 30 days notice, stating that the Member’s care (by this Provider) is being terminated. A copy of this letter should be mailed or faxed to Anthem's RCP Administrator with any applicable reassignment request forms. The RCP Administrator’s staff will work with the Member to select another Provider. Referrals made by the terminating Provider expire 30 calendar days after RCP Administrator’s receipt of the dismissal. Upon approval from the Administrator’s Medical Director, the expiration date may be extended under the following extenuating circumstances: New Provider is unable to see Member within 30 calendar days RCP Member eligibility terminates during the process of changing the Primary Medical Provider and the Member is auto-assigned to the dismissing Provider Claims Review and Adjudication A major factor in the success of the Right Choices Program is timely and appropriate claims adjudication. Procedures on proper claims submission can be found at www.indianamedicaid.com under the Manuals section, or within the applicable RCP Administrator’s claims processing manual. Claims for RCP Members may be suspended if all claim processing guidelines have not been followed. The following claims processing guidelines are specific to RCP Members: Claims from Referral Providers Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 6: Page 69 Chapter 6: Member Eligibility Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The referral Provider must receive from the Member’s Primary Medical Provider a referral authorizing the Member’s care for initial service. The referral Provider must confirm that the Member was not referred through other means, such as Member self-referral. The Primary Medical Provider must directly supply his or her IHCP Provider number to the referral Provider. This number should not be given to the RCP Member. If the referral Provider writes a prescription, it is recommended that the written referral accompany the prescription to the primary lock-in pharmacy. If the referral does not accompany the prescription, the pharmacy should contact the RCP Administrator to verify validity of the referral. Claims from Out-Of-State Providers Out-Of-State (OOS) generic Provider numbers will not bypass the lock-in list or be accepted as valid. Therefore, all Providers must have an IHCP Provider number to be a covered Provider for the Right Choices Program. If the Provider is out-of-state, the primary lock-in pharmacy should determine whether the Provider has an IHCP Provider number. If the Provider has an IHCP Provider number, he may be considered a covered Provider if the RCP Administrator deems the referral or use of service valid. If the out-of-state Provider does not have an IHCP Provider number, the Provider is not a RCP covered Provider and the RCP Administrator should be contacted in order to process an override, if appropriate. Claims from Lock-In Hospitals and Other Acute Care Facilities The primary lock-in hospital and other acute care facilities should file claims as they would for any nonRCP Member, but only if the hospital’s Indiana Health Coverage Program number is on the Member’s lock-in list. Member Eligibility Primary Lock-In Hospital Responsibilities in the RCP Selection of Primary Lock-In Hospital The primary lock-in hospital will be notified of lock-in status through a Hospital Provider Notification Letter generated via the state's Web interChange. The notification will be sent after Anthem's RCP Administrator receives the RCP Member's hospital selection. The primary lock-in hospital should be a full-service hospital and one where the Primary Medical Provider has been issued admitting privileges. Role of the Primary Lock-In Hospital The primary lock-in hospital is responsible for ensuring that RCP Members receive appropriate inpatient and outpatient services, including emergency room services. If a Member is found to be using the ER to obtain non-emergent services however, the Member’s Primary Medical Provider and Anthem's RCP Administrator should be notified. The hospital is strongly encouraged to educate Members on appropriate use of the ER and re-direct them to their assigned Primary Medical Provider as appropriate. The RCP Administrator will also provide ER education. Services Provided in the Emergency Room For Indiana's Medicaid Care Select (which serves Members with special health needs) and traditional Medicaid RCP Members, a referral is not necessary for services provided in the emergency room. However, only services rendered in the ER setting for medical emergencies will be reimbursed. Once the RCP Member has been stabilized, approval from the Primary Medical Provider must be obtained for Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 6: Page 70 Chapter 6: Member Eligibility Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan further treatment. The lock-in hospital should notify the Primary Medical Provider whenever a RCP Member is treated in the ER. Non-emergent services rendered in the ER will not be covered for Hoosier Healthwise and Healthy Indiana Plan Members. In this case, the hospital should refer the Member to his or her Primary Medical Provider, educate the Member on appropriate ER use, and notify the Member’s Primary Medical Provider of the visit. Hospital Services If the primary lock-in hospital is not the desired hospital for a specific inpatient or outpatient service, the Primary Medical Provider may refer the Member to a second hospital or facility and request that it be added to the Member’s lock-in list. The secondary hospital will be added only for the dates of service or time span specified by the Primary Medical Provider upon approval by the RCP Administrator. Prescriptions upon Discharge from Hospital If discharge prescriptions are being written for the RCP Member to be filled at the primary lock-in pharmacy, the hospital should contact the Member's Primary Medical Provider prior to discharge. The Primary Medical Provider should request that the discharge Provider be added to the Member's lock-in list for a specified timeframe. Please Note: If an emergency supply of discharge medications is provided by the hospital pharmacy to the RCP Member upon discharge, claims for the prescriptions will not be reimbursed by Indiana Medicaid unless there is an emergency indicator on the pharmacy claim and the Primary Medical Provider has made a valid referral for the discharge Provider to be added to the Member’s lock-in list for the specified timeframe. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 6: Page 71 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 7: UTILIZATION MANAGEMENT Hoosier Healthwise: Utilization Management Phone: Utilization Management Fax: Hours of Operation: 1-866-408-7187 1-866-406-2803 Monday to Friday, 8am-5pm Healthy Indiana Plan: Utilization Management Phone: Utilization Management Fax: Hours of Operation: 1-866-408-7187 1-866-406-2803 Monday to Friday, 8am-5pm Utilization Management Staff Availability Anthem makes UM staff available at least eight hours a day on normal business days to answer UMrelated calls. Member or Provider UM-related calls received are triaged to, and handled by, UM staff. UM staff sends outbound communications regarding UM-related inquiries during normal business hours only. After normal business hours, an answering service is available to take UM-related messages. If a Provider opts to request an authorization for admission for post-stabilization care after normal business hours our 24/7 NurseLine is available 24 hours a day, 7 days a week to Hoosier Healthwise and Healthy Indiana Plan Providers who need authorizations for post-stabilization medical admissions or behavioral health care. 24/7 NurseLine: 1-866-800-8780 TTY: 1-800-368-4424 Anthem will respond to a post-stabilization request within one hour, and a determination of the medical necessity will be rendered within 24 hours of that response. Please Note: The UM staff member will identify himself/herself by name, title and organization when initiating or returning calls regarding UM issues. Utilization Management Overview Anthem’s Utilization Management (UM) is a cooperative effort with Providers to promote, provide and document the appropriate use of quality health care resources. Our goal is to provide access to the right care, to the right Member, at the right time, in the appropriate setting. The UM team takes a multidisciplinary approach to meet the medical and psychosocial needs of our Members. Anthem’s decision-making process reflects the most up-to-date UM standards from the National Committee for Quality Assurance. When making Utilization Management (UM) decisions, Anthem utilizes the following criteria: Federal and State Mandates Member Benefits Anthem Medical Policy Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 72 Chapter 7: Utilization Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Clinical Utilization Management Guidelines Milliman Care Guidelines Anthem Policy and Procedures WellPoint Behavioral Health Medical Necessity Criteria The decision-making criteria used by the UM team are evidence-based and consensus-driven. We periodically update criteria as standards of practice and technology change. We involve practicing physicians in these updates and notify Providers of changes through Provider bulletins. Based on sound clinical evidence, the UM team provides the following service reviews: Prior authorizations Continued stay reviews Post-service reviews Please Note: Providers contracted with Anthem to serve Hoosier Healthwise and the Healthy Indiana Plan through an Accountable Care Organization (ACO), Participation Medical Group (PMG) or Independent Physician Association (IPA) should follow the guidelines and practices of the group. This includes: Authorization Covered benefits and services Claims submittal If you have questions, please contact your group administrator or your Anthem network representative. Decisions affecting the coverage or payment for services are made in a fair, consistent and timely manner. The decision-making incorporates nationally recognized standards of care and practice from sources including: American College of Cardiology American College of Obstetricians and Gynecologists American Academy of Pediatrics America Academy of Orthopedic Surgeons Cumulative professional expertise and experience Once a case is reviewed, decisions and notification time frames will be given for: Approval of services Modification of services Deferral of services Denial of services Please Note: We do not reward practitioners and other individuals conducting utilization reviews for issuing denials of coverage or care. There are no financial incentives for UM decision-makers that encourage decisions resulting in under-utilization. If you disagree with a Utilization Management decision and want to discuss the decision with the physician reviewer, you can call the UM department at: Hoosier Healthwise or Health Indiana Plan: 1866-408-7187 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 73 Chapter 7: Utilization Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Utilization Management Services Requiring Prior Authorization Air Ambulance Behavioral Health: For information about Behavioral Health Case Management, please see Chapter 5: Behavioral Health Services. Biofeedback Biopharmaceutical and Injectable Medications/Specialty Drugs Dental Services Durable Medical Equipment and Disposable Supplies Genetic Testing Home Health Care Services, including Hospice Care Hyperbaric Oxygen Therapy Infusion Therapy, including Chemotherapy Inpatient Hospital Services o Inpatient Skilled Nursing Facility (SNF) o Long-Term Acute Care Facility (LTAC) o Newborn Stays Beyond Mother o Rehabilitation Facility Admissions Laboratory Tests (specific) Out-Of-Network Referrals Outpatient Surgical Services (delivered in an ambulatory surgical center or outpatient hospital) Physician Services - Referrals to Specialists Radiology Services Select Outpatient Surgeries/Procedures Sensory Integration Therapy Transplant Services Vision Services A more comprehensive list of Services Requiring Prior Authorization can be found under the Prior Authorization and Preservice Review heading on the Provider Resources page of our website at: www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Please Note: For advanced imaging services, Anthem uses Diagnostic Imaging Guidelines developed by and proprietary to AIM Specialty Health. These advanced imaging guidelines are available on their website at www.aimspecialtyhealth.com/clinical-guidelines/agreementAccess Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 74 Chapter 7: Utilization Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Utilization Management Services That Do NOT Require Prior Authorization The following services do NOT require prior authorization for network Providers: Dialysis Emergency Services Family Planning/Well-Woman Check-Ups: (Hoosier Healthwise Members may self-refer to any Indiana Health Coverage Program (IHCP) in-network or out-of-network Provider; Healthy Indiana Plan Members may self-refer to any innetwork IHCP Provider) o Birth Control o Breast and Pelvic Exams o FDA-Approved Devices and Supplies for Family Planning (example: IUD) o Genetic Counseling o HIV/STD Screening o Lab Work Chiropractic services (Limitations noted depending on member’s selected package) Formulary glucometers and nebulizers Obstetrical Care, for in-network check-ups, routine testing and inpatient delivery. o Please complete the Notification of Pregnancy form and the Newborn Enrollment Notification Report, as appropriate In-network Physical and Occupational Therapy Physician Referrals, for in-network Specialists Standard X-Rays and ultrasounds Please Note: For benefits to be paid, the Member must be eligible on the date of service and the service must be a covered benefit. Except in an emergency, failure to obtain prior authorization may result in a denial for reimbursement. Utilization Management Prior Authorization Toolkit Our Prior Authorization Toolkit can be found under the Prior Authorization and Preservice Review heading on the Provider Resources page of our website at: www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. The toolkit contains information on Specialty Procedure Codes, as well as the Request for Preservice Review form. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 75 Chapter 7: Utilization Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Utilization Management Starting the Process When authorization of a health care service is required, call us with questions and requests, including requests for: Routine, non-urgent care reviews Urgent or expedited pre-service reviews Urgent concurrent or continued stay reviews An urgent request is any request for coverage of medical care or treatment with in which the length of time required to make non-urgent care determinations could result in one of the following: Could seriously jeopardize the life or health of the Member of the Member's ability to regain maximum function, based on a prudent layperson's judgment In the opinion of a practitioner with knowledge of the Member's medical condition, would subject the Member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request The UM team tries to return calls: Same day when received during normal business hours Next business day when the call is received after normal business hours Within 24 hours for all routine requests Providers can also fax the UM team and include requests for: Urgent or expedited pre-service reviews Non-urgent concurrent or continued stay reviews Faxes are accepted during and after normal business hours. Faxes received after hours will be processed the next business day. Utilization Management Provider Notifications of Changes to Authorization Procedures We notify providers of changes to authorization procedures via provider bulletins. Provider bulletins are distributed to all network providers and then posted under the Provider Communications heading on the Provider Resources page of our website: www.anthem.com. Bulletins posted on the Provider Resources page of our website are available to all providers. This Manual is then updated with changes during its next scheduled revision. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website Utilization Management Requesting Authorization To request a pre-service review or report a medical admission, call the UM department and have the following information ready: Member name and identification (ID) number Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 76 Chapter 7: Utilization Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Diagnosis with the International Classification of Diseases (ICD) code Procedure with the Current Procedural Terminology (CPT) code Date of injury or hospital admission and third party liability information (if applicable) Facility name (if applicable) Primary Medical Provider Specialist or attending physician name Clinical justification for the request Level of care Lab tests, radiology and pathology results Medications Treatment plan including time frames Prognosis Psychosocial status Exceptional or special needs issues Ability to perform activities of daily living Discharge plans Additional information to have ready for the clinical reviewer includes, but is not limited to: Office and hospital records History of the presenting problem Clinical exam Treatment plans and progress notes Diagnostic testing results Information on consultations with the treating practitioner Evaluations from other health care practitioners and Providers Photographs Operative and pathological reports Rehabilitative evaluations Printed copy of criteria related to the request Information regarding benefits for services or procedures Information regarding the local delivery system Patient characteristics and information Information from responsible family members All Providers—including physicians, hospitals and Ancillary Provider—are required to provide information to the UM department. Utilization Management Authorization Forms Our Prior Authorization Toolkit can be found under the Prior Authorization and Preservice Review heading on the Provider Resources page of our website at: www.anthem.com. For directions on how to Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 77 Chapter 7: Utilization Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Here are some tips for filling out the forms and getting the fastest response to your authorization request: Fill out the form online, then print and fax it. This ensures legibility. Fill out the form completely; unanswered questions typically result in delays. Access the forms online when you need one, rather than pre-printing and storing them. We revise the forms periodically, and outdated forms can delay your request. Utilization Management Requests with Insufficient Clinical Information When the UM team receives requests with insufficient clinical information, we will contact the Provider with a request for the information reasonably needed to determine medical necessity. We will make at least one attempt to contact the requesting Provider to obtain this additional information. If additional clinical information is not received a decision is made based upon the information available. Cases are either approved or denied coverage based on medical necessity and/or benefits. Members and Provider will be notified of the determination by letter. Utilization Management Pre-Service Review Time Frame For routine, non-urgent requests, the UM team will complete pre-service reviews within 7 calendar days from receipt of the request. Requests that do not meet medical policy guidelines are sent to the physician advisor or medical director for further review. Providers and Members will be sent notification by phone or fax within 7 calendar days from receipt of the request of the UM team’s approval, modification, deferral or denial. Utilization Management Urgent Pre-Service Requests For urgent requests, the UM team completes the pre-service review within 72 hours or as expeditiously as the member’s condition warrants from receipt of the request. Generally speaking, the Provider is responsible for contacting us to request pre-service review for both professional and institutional services. However, the hospital or Ancillary Provider should also contact Anthem to verify pre-service review status for all non-urgent care before rendering services. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 78 Chapter 7: Utilization Management Timeliness of Utilization Management Decisions Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan 1. Urgent, Pre-Service Requests: Within 72 hours of receipt of request or as expeditiously as the member’s health condition warrants of request 2. Urgent Concurrent Requests: Within 24 hours of request if the request is received 24 hours prior to the expiration of the previous authorization 3. Routine, Non-Urgent Requests: 7 days of request 4. Retrospective Review Requests: Within 30 days of request Utilization Management Emergency Medical Conditions and Services Anthem does not require prior authorization for treatment of emergency medical conditions. In the event of an emergency, Members can access emergency services 24 hours a day, 7 days a week. The facility does not have to be in-network. In the event that the emergency room visit results in the Member’s admission to the hospital, Providers must contact Anthem within 48 hours of admission. Utilization Management Emergency Stabilization and Post-Stabilization The emergency department’s treating physician determines the services needed to stabilize the Member’s emergency medical condition. After the Member is stabilized, the emergency department’s physician must contact the Member’s Primary Medical Provider for authorization of further services. The Member’s Primary Medical Provider is noted on the back of the ID card. If the Primary Medical Provider does not respond within one hour, the needed services will be considered authorized. The emergency department should send a copy of the emergency room record to the Primary Medical Provider’s office within 24 hours. The Primary Medical Provider should: Review the chart and file it in the Member’s permanent medical record Contact the Member Schedule a follow-up office visit or a Specialist referral, if appropriate If post-stabilization care is required, the hospital care provided in the 72-hour observation setting does not require authorization or notification. Claims for 72-hour observation will pay according to benefits, without clinical review. However, as with all non-elective admissions, notification must be made within 48 hours. The medical necessity of that admission will be reviewed upon receipt of notification and a determination of the medical necessity will be rendered within 24 hours of that notification. If a Provider requests authorization for admission for post-stabilization care after normal business hours, the Care Management team is available 24 hours per day, 7 days per week, and 365 days a year, to process such requests. A Utilization Management nurse will respond to a call within one hour, and a determination of the medical necessity will be rendered within 24 hours of that notification. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 79 Chapter 7: Utilization Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Utilization Management Referrals to Specialists The UM team is available to assist Providers in identifying a network Specialist and/or arranging for Specialist care. Keep the following in mind when referring Members: UM authorization is not required if referring a Member to an in-network Specialist for consultation or a nonsurgical course of treatment. UM authorization is required when referring to an out-of-network Specialist. UM authorization is required for an out-of-network referral when an in-network Specialist is not available in the geographical area. Provider responsibilities include documenting referrals in the Member’s chart and requesting that the Specialist provide diagnosis and treatment updates. Please Note: Please obtain a prior authorization approval number before referring Members to an outof-network Provider. For out-of-network Providers, we require this prior authorization for the initial consultation and each subsequent service provided. Utilization Management Out-Of-Network Exceptions There are several geographical exceptions to using only network Providers: Anthem Members are allowed to use the services of out-of-network nurse practitioners if no nurse practitioner is available in the Member’s service area. For HIP Members, Anthem makes covered services provided by Federally Qualified Health Clinics (FQHCs) and Rural Health Clinics (RHCs) available to Members out of-network if those clinics are not available in the Member’s service area and within Anthem’s network. If Anthem is unable to provide necessary covered medical services within 60 miles of the Member’s residence by Anthem’s Provider network, Anthem authorizes out-of-network services and covers the services for as long as those services are unavailable in-network. Anthem also allows Members with special needs that have been determined to need a course of treatment or regular care monitoring to directly access a Specialist via a standing referral from the Member’s Primary Medical Provider. Treatment provided by the Specialist must be appropriate for the Member’s condition. Utilization Management Hospital Inpatient Admissions Hospitals must notify the UM department of inpatient medical or behavioral health admissions within 24 or no later than the first business day after admission. Once notification of an inpatient admission is received, we will send a request for clinical information supporting the admission’s medical necessity. Evidence-based criteria are used to determine medical necessity and the appropriate level of care. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 80 Chapter 7: Utilization Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Utilization Management Clinical Information for Continued-Stay Review When a Member’s hospital stay is expected to exceed the number of days authorized during pre-service review, or when the inpatient stay did not have pre-service review, the hospital must contact us for continued stay review. We require clinical reviews on all Members admitted as inpatients to: Acute care hospitals Intermediate facilities Skilled nursing facilities We perform these reviews to assess medical necessity and determine whether the facility and level of care are appropriate. Anthem identifies Members admitted as inpatients by: Facilities reporting admissions Providers reporting admissions Members or their representatives reporting admissions Claims submitted for services rendered without authorization Pre-service authorization requests for inpatient care The UM team will complete continued-stay inpatient reviews within 24 hours of receipt of clinical information or sooner, consistent with the Member’s medical condition. UM nurses will request clinical information from the hospital on the same day they are notified of the Member’s admission and/or continued stay. Please include information on the discharge plans, including identified needs, with the initial review. Our UM department is available to assist with any care transition needs. If the information meets medical necessity review criteria, we will approve the request within 24 hours from the time the request is received. Requests that do not meet medical policy guidelines will be sent to the physician adviser or medical director for further review and determination. We will notify Providers within 24 hours of the request. We will send written notification of any denial or modification of the request to the Member and requesting Provider. Anthem makes decisions regarding approval or denial of urgent care within the 24 hours, but may extend the time frame in limited situations only when at least one of the following criteria is met: The request to approve additional days for urgent continued stay care is related to care not previously approved by Anthem and Anthem documents that it made at least one attempt to contact the Provider and was unable to obtain the needed clinical information within the initial 24 hours after the request for coverage of additional days. In this case, Anthem has up to 72 hours to make the decision. If the request by the provider/facility to extend urgent continued stay care was not made at least 24 hours prior to the expiration of the prescribed period of time or number of treatments, the request may be treated as an urgent preservice decision, Anthem may make the decision within 72 hours. The health plan documents that the Member voluntarily agrees to extend the decision-making time frame. In this case, Anthem has up to 72 hours to make the decision. If the decision time frame is extended and the decision is a denial or modification, the Provider and Member are notified verbally, electronically or in writing within72 hours of the receipt of the request. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 81 Chapter 7: Utilization Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Utilization Management Denial of Service Only a medical or behavioral health Provider who possesses an active professional license or certification can deny services for lack of medical necessity, including the denial of: Procedures Hospitalization Equipment When a request is determined to be not medically necessary, the requesting Provider will be notified of the following: The decision The process for appeal How to reach the reviewing physician for peer-to-peer discussion of the case Providers can contact the physician clinical reviewers to discuss any UM decision by calling the UM department. Utilization Management Post-Service/Retrospective Review Post-service review determines the medical necessity and/or level of care for services that were provided without getting required pre-service or concurrent/continued stay authorization. For inpatient admissions where no notification was received and no patient days were authorized, facilities are required to submit a copy of the medical record with the claim. Utilization Management Self-Referral Members do not need prior authorization and may self-refer to network Providers for the following services provided by Indiana Health Coverage Program-qualified Providers: Chiropractic Services Diabetes Self-Management Emergency Services Family Planning HIV/AIDS Case Management Immunizations Outpatient Behavioral Health (Not provided by a psychiatrist and must be in-network) Psychiatric Services Podiatric Routine Vision Utilization Management Second Opinions Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 82 Chapter 7: Utilization Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan There are several important guidelines regarding second opinions: A second opinion must be given by an appropriately-qualified health care professional. The second opinion must come from a Provider of the same specialty. The secondary Specialist must be within Anthem’s network and may be selected by the Member. (When there is no network Provider who meets the specified qualification, we may authorize a second opinion by a qualified Provider outside of the network upon request by the Member or Provider.) Second opinions regarding medical necessities are offered at no cost to our Members. Utilization Management Additional Services: Behavioral Health For information about Anthem’s Behavioral Health services, please see Chapter 5: Behavioral Health Services. Utilization Management Additional Services: Vision Care Anthem contracts with Vision Service Plan (VSP) Providers for basic vision care. For prior authorization of all vision services, contact: Vision Service Plan: 1-866-866-5641 or 1-800-428-4833 (TTY) Please Note: Vision services are covered only for Hoosier Healthwise Members. Healthy Indiana Plan Members do not have vision service benefits. Utilization Management Additional Services: Dental Care Basic dental services are considered a "carved out" service and are administered by the state. For basic dental services, Members can contact the following Indiana Health Coverage Programs (IHCP) dental specialists: Dental Clinics Endodontists General Dentistry Practitioners Mobile Dentists Oral Surgeons Orthodontists Pediatric Dentists Peridontists Prosthodontists Please Note: Dental services are covered only for Hoosier Healthwise Members. Healthy Indiana Plan Members do not have dental service benefits. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 7: Page 83 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 8: HEALTH SERVICES PROGRAMS Hoosier Healthwise: Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan: Anthem Provider Helpline: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Health Services Programs Overview Anthem’s health services programs are designed to help improve our Members' overall health and wellbeing by informing, educating and encouraging self-care in the early detection and treatment of existing conditions and chronic disease. These targeted programs, which supplement Providers' treatment plans, are divided into three categories: Preventive Care Programs, including the Initial Health Assessment program Health Management Programs, including ConditionCare, which promotes knowledge and encourages self-care for specific medical conditions and chronic disease, and New Mother and Baby Post Delivery Outreach, a program designed to identify mothers and babies with postdelivery complications Health Education, including the 24/7 NurseLine for all health-related questions and instruction on the proper use of emergency room services Health Services Programs Preventive Care: Health Screenings & Immunizations One of the best ways to promote and protect good health is to prevent illness. Hoosier Healthwise and Healthy Indiana Plan Members are covered for routine health screenings and immunizations. Additionally, our health services programs provide Members with guidelines, reminders and encouragement to stay well. Our Members may receive: Information about health issues Flu shot reminders Health screening reminders, such as breast and cervical cancer screenings Provider Responsibilities The following are Provider responsibilities that help Members maintain healthy lifestyles: Document all health care screenings, immunizations, procedures, health education and counseling in the Member’s medical record Provide immunizations as needed at all Well Child visits and according to the schedule established by the Advisory Committee on Immunization Practices (ACIP), American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP) Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 84 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Refer Members, as appropriate, to Dentists, Optometrist/Ophthalmology or other Specialists as needed; document referrals in the Member’s medical record Schedule preventive care appointments for all children following the AAP periodicity schedule Health Services Programs Preventive Care: Initial Health Assessments Initial Health Assessments give Providers the baseline they need to assess and manage a Member’s physical condition. Once the Initial Health Assessment has been completed, Providers can give our Members the kind of educational support that allows them to become more actively engaged in their own treatment and preventive health care. Initial Health Assessments (IHA) of new Members should be performed by the Primary Medical Provider within 90 days of enrollment. The IHA consists of the following categories of patient information: Patient history Physical examination Developmental assessment Vision & Hearing Screening Health Education Screenings & Immunizations Behavior Assessment Please Note: An Initial Health Assessment is not necessary under the following conditions: If the new Member is one of the Primary Medical Provider’s existing patients (but new to us) with an established medical record showing baseline health status. This record must include sufficient information for the Primary Medical Provider to understand the Member’s health history and provide treatment recommendations as needed. If the new Member is not an existing patient, transferred medical records can also meet the requirements for an IHA if a completed health history is included. Health Services Programs Preventive Care: HealthWatch In Indiana, the Early and Periodic Screening, Diagnostic and Treatment Services Program (EPSDT) for children is called HealthWatch. HealthWatch is a children’s preventive health care program providing initial and periodic examinations and medically necessary follow-up care. As an integral part of this program, Primary Medical Providers offer age-appropriate preventive care screening and testing during each Well Child visit and during an acute illness episode, if appropriate. The age range for these screenings depends upon the Member's health plan: Hoosier Healthwise: Birth to 21 years of age Healthy Indiana Plan: Ages 19 and 20 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 85 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan HealthWatch Screening Requirements Primary Medical Providers should offer health education, counseling and guidance to the Member, parent or guardian. An evaluation of age-appropriate risk factors should be performed at each visit. In addition, Primary Medical Providers should perform the following: A comprehensive health and developmental history, including both physical and behavioral health development A comprehensive unclothed physical exam, which includes pelvic exams and Pap tests for sexually active females Appropriate immunizations according to age and health history Documented and current immunizations Laboratory tests, including screenings for blood lead levels Nutritional assessment Tuberculosis screening Dental Assessment Sensory screening (vision and hearing) Health Education For Healthy Indiana Plan Members HIP Members ages 19 and 20 are eligible for EPSDT services, including lead toxicity screening and hearing aids HealthWatch Responsibilities Information on our preventive care programs is provided in Anthem’s Member Handbook which is sent to new Members at the time of enrollment. Member newsletters and the Member website include special features about the HealthWatch program, on-going reminders on the importance of an initial health assessment, Well Child visits, immunizations and regular checkups. In addition, Anthem uses an automated call system to reach out to Members as outlined below: Initial health assessment reminder calls to all newly-enrolled Members within 60 days of enrollment Immunization reminder calls to the parents/guardians of Members at ages 3 months, 6 months, 9 months, 12 months, 15 months and 18 months old Annual preventive care/well visit reminder calls to Members 2 through 20 years of age on their birth months Providers should document unsuccessful attempts to contact a Member, attempts to schedule an IHA, missed appointments or the Member’s refusal to schedule an IHA, as evidence that an IHA was attempted. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 86 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Health Services Programs Preventive Care: Childhood Lead Exposure Testing/Free Blood Test Kits The Centers for Medicare and Medicaid Services require that all children enrolled in Medicaid be tested for lead exposure at 1 and 2 years of age. Children from 3 to 6 years of age who have not been tested also need screening regardless of their risk factors. Please Note: Completion of a lead risk assessment questionnaire does not fulfill this screening requirement; a blood draw is also required. Anthem has contracted with MEDTOX Laboratories to provide free, easy-to-use lead exposure screening kits to Providers. These kits contain: A blood sample card Lancets (upon request) A plastic, sealable storage bag Pediatric lead/hemoglobin requisition form Prepaid envelope (large envelopes are available upon request) To order your free MEDTOX lead exposure blood testing kits, please call MEDTOX to arrange for an initial order and to set up an account. MEDTOX: 1-888-834-8315 Health Services Programs Preventive Care: Member Incentives (Healthy Indiana Plan Only) The Healthy Indiana Plan (HIP) has a built in reward for Members who have their required preventive services and have money remaining in their POWER Account at the end of their benefit period.The full unspent balance rolls over to reduce the amount they have to pay in the next benefit period when they have their required preventive services. If the Member does not have their required preventive services, only the portion of the balance that the Member contributed can rollover to reduce their contributions in the subsequent benefit period. The Healthy Indiana Plan will consider all Members as having received appropriate preventive services if they had one of the following services during their 12 month benefit period: a preventive exam or general physical; Well Woman Exam (including pap and/or mammogram if applicable), Colorectal Cancer Screening (if age appropriate), Diabetes Testing HbA1c, LDL, Eye Exam and/or Kidney Function (if diabetic), Cholesterol Testing (if history of Coronary Heart Disease), or Flu shot. If the Member does not receive all necessary preventive care, only the Member's contribution to the POWER Account will be rolled over; the state's portion will be returned to the state. The POWER Account, which is created by contributions from the Member, the Member's employer or Community Organization (if applicable), and the State, is equal to the $1,100 yearly deductible for health care services. Health Services Programs Health Management: ConditionCare The more our Members know about their medical conditions and chronic disease, the better they will be able to follow through with treatment therapies and take charge of their own health. That’s the thinking Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 87 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan behind our special health services program, ConditionCare, which was designed to supplement and enhance Providers' treatment plans and make them more effective, easier to understand and easier to follow. The ConditionCare program relies on a strong partnership between Providers, who decide on the proper course of treatment, and a dedicated staff of program nurses, called “Nurse Coaches,” who help Members better understand their condition, treatment and follow through. ConditionCare targets the following conditions: Asthma (Pediatric and Adult) Cardiovascular Conditions (Coronary Artery Disease and Heart Failure) Chronic Obstructive Pulmonary Disease Diabetes (Types 1 & 2) ConditionCare offers a number of important benefits to Providers, including: Saving time for the Provider and staff by answering Member questions and responding to concerns Supporting the Provider/Member relationship by encouraging Members to follow their doctor’s treatment plan Informing Providers with updates on the Member’s progress Health Services Programs Health Management: ConditionCare for Asthmatic Members Anthem works collaboratively with Providers in the identification, management and treatment of child and adult Members with asthma. ConditionCare for Asthmatic Members was designed to educate our Members and reinforce Providers’ treatment plans, which should include a written Asthma Action Plan to improve self-management skills. The ConditionCare program is based on the National Institute of Health (NIH) and National Heart, Lung and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma. Find out more about these guidelines at: www.nhlbi.nih.gov/guidelines/asthma. Member enrollment and participation in ConditionCare for Asthmatic Members program is based on either an opt-out process for high-risk Members or an opt-in process available to Members who selfrefer to the program. Identified Members are automatically enrolled in the program and receive interventions according to risk stratification. A Member may opt-out of the program at any time by contacting Anthem. Primary Medical Providers should follow these ConditionCare guidelines: Assess Members for asthma using the NIH risk categories. Provide each diagnosed Member with a written Asthma Action Plan that describes medication dosage and level of care needed, based on peak-flow readings. Encourage the Member to participate in our ConditionCare for Asthmatic Members program. Refer Members to asthma education classes by calling our Health Management and Education department at: 1-800-319-0662. Coordinate care with Care Management, pharmacy and Specialists, as needed. Document all referrals and treatments related to asthma in the Member’s medical record. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 88 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan File the Member-specific report with the Member’s risk stratification in the medical record. Request asthma education materials by calling: Anthem Medicaid Provider Helpline:: 1-866-408-6132 Anthem Provider Helpline: 1-800-345-4344 Please Note: The Asthma Action Plan is available on the National Heart, Lung and Blood Institute's website: www.nhlbi.nih.gov/health/prof/lung/asthma/naci/discover/action-plans.htm. Health Services Programs Health Management: ConditionCare for Members with Cardiovascular Conditions Anthem designed the ConditionCare for Members with Cardiovascular Conditions program as a multidisciplinary approach to heart disease. The program empowers Members through education and self-management. Primary Medical Providers are encouraged to provide each Member with ongoing treatment and perform the appropriate physical and laboratory examinations following guidelines from the American Heart Association (AHA) and the National Institutes of Health (NIH). They are also encouraged to: Improve quality of care in accordance with the AHA clinical practice guidelines for Congestive Heart Failure (CHF) and Coronary Artery Disease (CAD). Improve quality of life for Members with CHF or CAD. Refer Members to the ConditionCare Program to facilitate Member/Provider communication and to encourage Members to take a more active role in the management of their disease. Reduce exacerbation of conditions and secondary complications. Request cardiovascular educational materials by calling our Medicaid Provider Helpline at: 1-866-408-6132. The ConditionCare for Members with Cardiovascular Conditions program adheres to the following clinical practice guidelines: Cardiovascular Disease: American Heart Association (AHA) Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: http://circ.ahajournals.org/cgi/content/full/106/3/388 Congestive Heart Failure: Diagnosis and Management of Chronic Heart Failure in the Adult — AHA: http://circ.ahajournals.org/cgi/content/full/112/12/1825 Hypertension: Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) — NHLBI: www.nhlbi.nih.gov/guidelines/hypertension/index.htm Member enrollment and participation in the ConditionCare for Members with Cardiovascular Conditions program is based on either an opt-out process for high-risk Members or an opt-in process available to Members who self-refer. Identified Members are automatically enrolled in the program and receive interventions according to risk stratification. A Member may opt-out of the program at any time by contacting Anthem. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 89 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Health Services Programs Health Management: ConditionCare for Members with Chronic Obstructive Pulmonary Disease (COPD) ConditionCare for Members with Chronic Obstructive Pulmonary Disease (COPD) was designed to augment the care of Members with COPD. Anthem works collaboratively with Providers in the identification, management and treatment of this disease. Anthem supports the initiative of the Global Strategy for Diagnosis, Management and Prevention of COPD, also known as GOLD. For more information on this initiative, go to the GOLD website: www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html Primary Medical Providers are encouraged to follow these guidelines: Assess and treat Members according to COPD Guidelines. Refer Members for appropriate laboratory and screening tests. Refer Members to the ConditionCare for Members with Chronic Obstructive Pulmonary Disease program. File a Member-specific report with the Member’s risk stratification and the date of the last COPD screening in the medical record. Coordinate Care Management, pharmacy and Specialists as needed. Document all referrals and treatments related to COPD in the Member’s medical record. Request COPD educational materials by visiting our website at www.anthem.com or calling our Medicaid Provider Helpline at: 1-866-408-6132. Member enrollment and participation in the ConditionCare for Members with Chronic Obstructive Pulmonary Disease program is based on either an opt-out process for high-risk Members or an opt-in process available to Members who self-refer. Identified Members are automatically enrolled in the program and receive interventions according to risk stratification. A Member may opt-out of the program at any time by contacting Anthem. Health Services Programs Health Management: ConditionCare for Diabetic Members ConditionCare for Diabetic Members was designed to augment the care of children and adult Members with diabetes. Anthem works collaboratively with Providers in the identification, management and treatment of this disease. Primary Medical Providers are to provide each diabetic Member with ongoing treatment and perform the appropriate physical and laboratory examinations following the Diabetes Care Guidelines from the American Diabetes Association. Primary Medical Providers are encouraged to follow these guidelines: Assess and treat Members according to the Diabetes Care Guidelines. Refer Members for appropriate laboratory and screening tests. Refer Members to the ConditionCare for Diabetic Members program. File a Member-specific report with the Member’s risk stratification and the date of the last diabetic screening in the medical record. Coordinate Care Management, pharmacy and Specialists as needed. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 90 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Document all referrals and treatments related to diabetes in the Member’s medical record. Request diabetes educational materials by calling our Medicaid Provider Helpline at: 1-866-4086132. Member enrollment and participation in the ConditionCare for Diabetic Members program is based on either an opt-out process for high-risk Members or an opt-in process available to Members who selfrefer. Identified Members are automatically enrolled in the program and receive interventions according to risk stratification. A Member may opt-out of the program at any time by contacting Anthem. Health Services Programs Health Management: Future Moms Anthem provides comprehensive perinatal services to our expectant Members through a variety of programs including the Future Moms program, case management of high-risk pregnancies and health education materials and classes. The main objective of the Future Moms program is to help Members achieve positive birth outcomes by encouraging early and ongoing prenatal and postpartum care, and by increasing Member access to perinatal care. At Anthem, we work in partnership with Members, their Primary Medical Provider and their obstetrician/gynecologist. We also coordinate care for high-risk pregnancies and actively collaborate with Providers to assist us in identifying pregnant Members. Upon identification of pregnant Members, we provide the Member with a Future Moms program information packet that contains health education on prenatal and postpartum care. Members enrolled in the Future Moms program are provided with: Access to prenatal education classes Case management for high-risk pregnancies Educational mailings with perinatal information Referral to community-based resources as needed Members may self-refer to Future Mom classes, which include early prenatal, childbirth education, baby care and breastfeeding classes. Members can register by calling our Health Management and Education department at: 1-800-319-0662. Provider Assessment of Pregnancy Risk The Primary Medical Provider or prenatal care physician should assess all pregnant Members for highrisk indicators during the initial prenatal care visit. For all pregnant Members, the Provider needs to: Complete a Notification of Pregnancy (NOP) form and submit it online to the state per their instructions. Providers may access the form by logging onto the state’s Web interchange site at https://interchange.indianamedicaid.com/Administrative/logon.aspx. Refer Members to prenatal education, childbirth education, and breastfeeding classes; Members can register by calling our Health Management and Education department at: 1-800-319-0662. Document all referrals in the Member’s medical record. Schedule the Member for a postpartum visit. Breastfeeding Support Tools and Services Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 91 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the American Public Health Association recognize breastfeeding as the preferred method of infant feeding. Providers should encourage breastfeeding for all pregnant women unless it is not medically appropriate. To support this goal, we ask you to: Assess all pregnant women for health risks that are contraindications to breastfeeding, such as AIDS and active tuberculosis. Provide breastfeeding counseling and support to postpartum women immediately after delivery. Assess postpartum women to determine the need for lactation durable medical equipment such as breast pumps and breast pump kits. Document all referrals and treatments related to breastfeeding in the Member's medical record. (Pediatricians should document frequency and duration of breastfeeding in baby’s medical record.) Refer Members to prenatal classes prior to delivery by calling the Health Management and Education department at: 1-800-319-0662. Refer pregnant and postpartum women to 24/7 NurseLine for information, support and referrals. Refer pregnant women to community resources that support breastfeeding such as Women, Infants and Children (WIC) at: 1-800-522-0874. Support continued breastfeeding during the postpartum visit. Health Services Programs Health Management: New Mother and Baby Post-Delivery Outreach Program The New Mother and Baby Post-Delivery Outreach Program is designed to identify mothers and babies with post-delivery complications, as well as those in need of newborn health care and/or parenting education. Anthem will contact new mothers by telephone within four days of receipt of the Newborn Enrollment Notification Report. The purpose of the call is to find out if the new mother is experiencing any complications, assess her awareness of newborn health care needs, offer parenting education resources and confirm that she has a postpartum and Well Baby appointment scheduled with her Provider within 21-56 days. A second call will be made 14 days after the first call. The program will allow Anthem and its Providers to: Establish eligibility for care management programs Ensure mothers and babies receive appropriate medical care Increase postpartum and Well Child follow-up visits Enhance Member engagement Increase quality health care outcomes for mothers and their babies Raise Healthcare Effectiveness Data and Information Set (HEDIS) scores For this initiative to be effective, Providers should submit the Newborn Enrollment Notification Report to Anthem within 3 days of delivery. The form is located under Clinical and Preventive Care Tools in the Forms Library on the Provider Resources homepage. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. If you have any questions about the New Mother and Baby Post-Delivery Outreach Program, contact Anthem's Utilization Management department at: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 92 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Utilization Management: 1-866-408-7187 Health Services Programs Health Education: No-Cost Classes Anthem offers health education services and programs to meet the specific health needs of our Members to promote healthy lifestyles and improve the health of those living with chronic diseases. Health education classes take place at hospitals and/or community-based organizations. Classes are available at no charge to the Member and are accessible upon self-referral or referral by Anthem network Providers. Classes vary from county to county, and include the following: Asthma Management Childbirth/Lamaze Diabetes Management Injury Prevention Nutrition Parenting/Well Child Prenatal Education Sexually Transmitted Infections (STIs) Smoking Cessation/Tobacco Prevention Substance Abuse Members receive information about health education classes through enrollment materials, Member newsletters, Practice Consultants (PCs) and Provider offices. To schedule a health education class, Members should call the Health Management and Education department at: 1-800-319-0662. Follow-Up After attending the class at a participating hospital or community-based organization, we send an Attendance Confirmation letter to the Member’s Primary Medical Provider with the Member’s name, ID number and the title of class attended. If a Member does not show up for the registered class, we mail a No Show letter to the Member’s Primary Medical Provider. Primary Medical Providers must document health education services in the Member’s medical record. For more information on health education classes, Members or Providers can call our Health Management and Education department at: 1-800-319-0662. Health Services Programs Health Education: 24/7 NurseLine We recognize that questions about health care prevention and management don’t always come up during office hours. 24/7 NurseLine, a 24 hours a day, 7 days a week phone line staffed by registered nurses, provides a powerful Provider support system and is an invaluable component of after-hours care. 24/7 NurseLine allows Members to closely monitor and manage their own health by giving them the ability to ask questions whenever they come up. 24/7 NurseLine: 1-866-800-8780 or 1-800-368-4424 (TTY) Members can call 24/7 NurseLine for: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 93 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Self-care information, including assistance with symptoms, medications and side-effects, and reliable self-care home treatments Access to specialized nurses trained to discuss health issues specific to our teenage Members Information on more than 300 health care topics through the 24/7 NurseLine audio tape library Providers may use 24/7 NurseLine as a resource for Members to call for non-emergent questions and information. Please Note: 24/7 NurseLine has access to telephone interpreter services for callers who do not speak English. All calls are confidential. Health Services Programs Health Education: Weight Management Programs Healthy Lifestyles Healthy Weight is a comprehensive weight management program that engages, educates, motivates and supports people in achieving a healthy weight. Healthy Lifestyles Healthy Weight helps each individual Member develop a personalized weight management plan tailored to their unique needs. The plan is based on their current state of health and risk factors, behaviors and lifestyle. It also takes into consideration the psychological and preference factors associated with the change process. Childhood Obesity Education “Get Up and Get Moving!” is our health education program addressing childhood obesity. The focus is to empower families with young children with knowledge of proper nutrition and physical activity. The key educational concept of this program is that regular exercise and nutrition are the basis of a healthy family lifestyle. Family workbooks are available in English and Spanish to parents of children ages 6 to 12 by calling our Medicaid Provider Helpline at: 1-866-408-6132. Health Services Programs Health Education: Tobacco Treatment Programs Anthem Blue Cross supports the National Cancer Institute's health education program for Members who want to quit smoking. The program's goals are to: Assist Members in improving their health status and quality of life by becoming more actively involved in their own care Encourage Members to quit smoking Support Members' tobacco cessation efforts with resources and education The National Cancer Institute has developed a booklet called "Clearing the Air." The booklet provides tips to support tobacco cessation by identifying available resources and offering tools for quitting, such as: Winning strategies of successful quitters Coping skills for fighting the urge to smoke Strategies for success after a relapse National Quit Line contact information National Quit Line: 1-877-44U-QUIT (1-877-448-7848) Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 94 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Requests for the booklet can be made in several ways. Once enrolled, Members can make a direct request by using the contact information provided in the Plan's welcome packet. Or, they can request the booklet through the 24/7 NurseLine. They can also make the request in person by talking to care management nurses or social workers. The booklet is available to download from the following websites: Smokefree.gov www.smokefree.gov National Cancer Institute: https://pubs.cancer.gov/ncipl/detail.aspx?prodid=P133Tobacco Cessation Program: Indiana Tobacco Quitline Providers are encouraged to refer Members age 18 and over to the Indiana Tobacco Quitline, which is confidential and free of charge to Indiana residents. The Indiana Tobacco Quitline offers education and coaching over the telephone, as well as Nicotine Replacement Therapy patches and lozenges, and the medication Varenicline (Chantix). Members are limited to 12 weeks of medications and 8 hours of counseling per rolling 12-month period. Co-payments of 50 cents are required for over-the-counter medications, and co-payments of $3 are required for prescription medications. Counseling is required to be a part of any medication treatment plan. Indiana Tobacco Quitline: Hours of Operation: Website: 1-800-QUIT-NOW 8 am-12 am Monday to Sunday www.indianaquitline.net Healthy Lifestyles Tobacco Free helps each Member develop a personalized "quit tobacco plan." The plan is based on the Member's current state of health, their risk factors, behaviors and lifestyle. It also takes into consideration the psychological and preference factors associated with the change process. Healthy Lifestyles Tobacco Free provides each individual with the support, resources and motivation to successfully achieve their goal. Provider Assessment of Tobacco Use The following are Provider guidelines to help Members quit smoking: Assess the Member's smoking status and offer advice about quitting. Refer Members to the National Quit Line or Indiana's Tobacco Quitline, a free, phone-based counseling service. Services are available 7 days a week in more than 170 languages and include: One on one coaching Resources for Providers who want to improve patient outcomes Support for family and friends who want to help loved ones stop smoking Use the state’s online Notification of Pregnancy (NOP) form at https://interchange.indianamedicaid.com/Administrative/logon.aspx as a way to notify us, through the state, of pregnant women who smoke. Women are more likely to quit smoking during pregnancy. Encourage pregnant women to stop smoking and not resume after pregnancy. Additional Resources to Help Members Stop Smoking Anthem offers one additional educational resource to help women who are pregnant or of childbearing age quit smoking and avoid starting again. Copies of Quit Smoking For Your Baby's Sake can be downloaded from the Health Education Programs section of the Providers Resources page at: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 95 Chapter 8: Health Services Programs Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Provider types who may perform tobacco cessation counseling include: Physicians Physician assistants Nurse practitioners Registered nurses Psychologists Pharmacists Dentists Counseling is required as a part of any covered tobacco cessation course of treatment. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 8: Page 96 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 9: CLAIMS & BILLING Hoosier Healthwise Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Fax: Hours of Operation: Healthy Indiana Plan Anthem Provider Helpline Phone: Anthem Provider Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Claims & Billing Overview Having a fast and accurate system for processing claims allows Providers to manage their practices and our Members’ care more efficiently. With that in mind, Anthem has made claims processing as streamlined as possible. Share the following guidelines with your staff, billing service and electronic data processing agents as appropriate. Submit “clean” claims, making sure that the right information is on the right form. Submit claims as soon as possible after providing service. Submit claims within the contract filing time limit. For Anthem Members enrolled in Hoosier Healthwise: Providers should follow claims and billing guidelines outlined in the Indiana Health Coverage Programs (IHCP) manual. The chapter on billing instructions may be found on the state website: http://provider.indianamedicaid.com/ihcp/manuals/chapter08.pdf. For Anthem Members enrolled in the Healthy Indiana Plan (HIP): Anthem uses Medicare NCCI coding guidelines. Healthy Indiana Plan claims will be reimbursed at 100% of Indiana Medicare or 130% of Medicaid if a Medicare fee is not available. Please refer to the Indiana Health Coverage Programs HIP Reimbursement Manual at http://provider.indianamedicaid.com/general-providerservices/manuals.aspx. Please Note: In order to be a HIP Provider, you must also contract with the Indiana Health Coverage Programs (IHCP) as a Medicaid Provider. Providers who are contracted with Anthem to serve Hoosier Healthwise and Healthy Indiana Plan through an Accountable Care Organization (ACO), Participating Medical Group (PMG) or Independent Physician Association (IPA) should follow the guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or Anthem network representative. McKesson ClaimsXten For Hoosier Healthwise and the Healthy Indiana Plan, Anthem uses claims editing software from McKesson called ClaimsXten. ClaimsXten incorporates the McKesson editing rules that determine whether a claim should be paid, rejected or requires manual processing. These editing rules assess Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes on the CMS-1500 form. A claim auditing action then determines how the Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 97 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan procedure codes and code combinations will be adjudicated. The auditing action recognizes historical claims related to current submissions and may result in adjustments to previously processed claims. You can find descriptions of specific reimbursement policies in this manual. ClaimsXten may be updated periodically. Anthem will notify Providers with advance notice as per your Provider agreement. For the latest information and current ClaimsXten rules, please look under Forms and Tools on the Provider Resources page at www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Claims & Billing Submitting “Clean” Claims Claims submitted correctly the first time are called “clean,” meaning that all required fields have been filled in and that the correct form was used for the specific type of service provided. A claim may be returned if it is submitted with incomplete or invalid information. If you use the Electronic Data Interchange (EDI), claims will be returned for incomplete or invalid information. They may also be returned if they aren't submitted with the proper HIPAA-compliant code set. In each case, an error report will be sent to you and the claim will not be sent through for payment. You and your staff are responsible for working with your EDI vendor to ensure that “errored out” claims are corrected and resubmitted. Generally, there are two types of forms you’ll need for reimbursement. They are: CMS-1500 for professional services CMS-1450 (UB-04) for institutional services These forms are available in both electronic and hard copy/paper formats. Click on the form name to link to a copy of the form with a general description of each field and the information required. Please Note: Using the wrong form or not correctly or completely filling out the form causes the claim to be returned. This results in processing and payment delays. Claims & Billing Claims Filing Limits Claims must be submitted within the contracted filing limit to be considered for payment. Claims submitted after that time period will be denied. Please Note: Anthem is not responsible for a claim never received. If a claim is submitted inaccurately, delayed resubmission may cause you to miss the filing deadline. Claims must pass basic edits in order to be considered received. To avoid missing deadlines, submit “clean” claims as soon as possible after delivery of service. Filing limits are determined as follows: If Anthem is the primary payer, you have a specific time period between the last date of service on the claim and the Anthem receipt date: 90 calendar days. If Anthem is the secondary payer, you have a specific time period between the other payer’s Remittance Advice (RA) date and the Anthem receipt date: 90 calendar days. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 98 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Claims & Billing Claims from Non-Contracted Providers Anthem accepts the following claims from non-contracted Providers under certain conditions and within certain time frames: Emergency Services: 365 calendar days from date of service or discharge date. Medicaid Enrolled: 90 calendar days with Prior Authorization if services are not available in state. Newly Medicaid Enrolled: 90 calendar days of the date the new Provider Identifier is issued, and within 365 days of the date of service. Non-Indiana Medicaid Enrolled: 365 calendar days with Prior Authorization from date of service. Providers are asked to file a retroactive contract with IHCP. Claims & Billing Methods for Submission There are two methods for submitting a claim: Electronically through Electronic Data Interchange (preferred) Paper or "hard copy" Electronic submission through Anthem's Electronic Data Interchange is preferred for accuracy, convenience and speed. Providers will receive notification that an electronic claim has been submitted within 24 hours. If the claim contains all required information, Anthem enters it into the claims system for processing and sends you either a Remittance Advice (RA) or a Claims Disposition Notice (CDN) when the claim is finalized. Clean electronic claims are paid within 21 calendar days; clean paper claims are paid within 30 calendar days. Anthem pays interest on clean claims paid after these time frames. Claims & Billing Prefixes Required on the CMS-1500 and CMS-1450 Forms For each claim, you need to submit a CMS-1500 or CMS 1450 (UB-04) form. The claims form must include the full Member ID number and a 3-letter alpha prefix: The alpha prefix YRH for Hoosier Healthwise The alpha prefix YRK for the Healthy Indiana Plan Hoosier Healthwise Members must present their State-issued Hoosier Healthwise ID card. Healthy Indiana Plan Members must present their Anthem ID card. Please Note: The prefix is necessary to route the claim to the right location for prompt processing. If the prefix is omitted, your claim may go to the wrong location and cause payment delay. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 99 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Claims & Billing Electronic Claims Electronic filing methods are preferred for accuracy, convenience and speed. Electronic Data Interchange (EDI) allows Providers and facilities to submit and receive electronic transactions from their computer systems. EDI is available for most common health care business transactions. For more information on EDI, please contact the Anthem EDI Solutions Helpdesk at: Anthem EDI Solutions Helpdesk: 1-800-470-9630 Hours of Operation: Monday to Friday, 8am-4:30pm Eastern Time EDI Solutions E-mail: [email protected] For the most detailed information, there is a website dedicated to sharing billing information with Providers and EDI vendors, including clearinghouses, software vendors and billing agencies. This information includes details on how to submit, receive and troubleshoot electronic transactions. To access all EDI manuals, forms and communications, go to: www.anthem.com/edi. The following is available online: EDI registration information and forms EDI contacts and support information EDI communications and electronic submission tips Information on electronic filing benefits and cost-savings Filing instructions for EDI submission of eligibility, benefit and claim status inquiries Anthem HIPAA Companion Guide and EDI User Guide with complete information on submitting and receiving electronic transactions Anthem report descriptions Lists of clearinghouses, software vendors and billing agencies FAQ's about electronic transactions Information and links to the Health Insurance Portability and Accountability Act (HIPAA) website Contractual agreements with our trading partners Claims & Billing National Provider Identifier The National Provider Identifier (NPI) is a 10-digit, all numeric identifier. NPIs are issued only to Providers of health services and supplies. As one provision of the Health Insurance Portability and Accountability Act of 2010 (HIPAA), the NPI is intended to improve efficiency and reduce fraud and abuse. NPIs are divided into two types: Type 1: Individual Providers, which includes but is not limited to Physicians, Dentists and Chiropractors Type 2: Hospitals and medical groups, which includes but is not limited to hospitals, group practices, Federally Qualified Health Centers and Rural Health Centers For billing purposes, NPIs should be used with the following guidelines: Claims must be filed with the appropriate NPI for billing, rendering and referring Providers. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 100 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The NPI must always be attested with Indiana Health Coverage Programs (IHCP) in the same manner as contracted with Anthem, including effective dates for individual Providers within groups. Claims will be denied when the NPI listed is not the same number attested with IHCP. Providers may apply for an NPI online at the National Plan and Provider Enumeration System (NPPES) website: www.nppes.UMs.hhs.gov. Or, you can get a paper application by calling NPPES at: NPPES: 1-800-465-3203 The following websites offer additional NPI information: Centers for Medicare and Medicaid Services: https://www.UMs.gov/nationalprovidentstand/ National Plan and Provider Enumeration System (NPPES): https://nppes.UMs.hhs.gov/NPPES/NPIRegistryHome.do Workgroup for Electronic Data Interchange: www.wedi.org/ National Uniform Claims Committee: www.nucc.org/ Claims & Billing Use of Referring Provider's NPI on Claims Submissions If the Primary Medical Provider refers a Member to a Specialist or another Provider, the Primary Medical Provider must provide his own NPI. The Specialist is then required to add the Primary Medical Provider's NPI when submitting claims for the referred Member. If the Primary Medical Provider does not provide their NPI at the time of referral, the billing Provider is responsible for obtaining that information. That can be done by calling the Primary Medical Provider's office or by going online to the NPI Registry website: NPI Registry Website: https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do There are some exceptions to the requirement of providing the referring Primary Medical Provider's NPI when submitting a claim for services provided to a Member not assigned to you. The exceptions include the following: If no Primary Medical Provider is identified for the Member If one physician is on call or covering for another (in this case, the billing Provider must complete Box 17b of the CMS-1500 claim form to receive reimbursement) If the Provider is in the same Provider group, or has the same tax ID or NPI as the referring physician and is an approved Provider type Services were provided after hours (codes 99050 & 99051) Emergency services (services performed in place of service 23) Family Planning services Diagnostic specialties such as lab and X-ray services Anesthesia claims Professional Inpatient claims Obstetrics/Gynecology claims If the billing or referring physician is from any of the following: o Federally Qualified Health Center o Indian Health Provider or an Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 101 Chapter 9: Claims and Billing o Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Urgent Care Center Self-referrals: Members may self-refer for certain services that are provided by an Indiana Health Coverage Program (IHCP) qualified Provider, including: o Psychiatric services o Family Planning services o Emergency services o Diabetes Self-Management services o Behavioral Health Services Claims & Billing Unattested NPIs Anthem will deny claims with an unattested NPI, even if you provide legacy information. **Attestation: The process of registering and reporting your NPI with your state Medicaid agency. Providers serving Indiana Medicaid Members are required to register and attest their NPI with Indiana's Family and Social Services Administration (FSSA). You can attest your NPIs on the FSSA website at: http://provider.indianamedicaid.com/become-a-provider.aspx by selecting National Provider Identifier (NPI). Claims & Billing Paper Claims Paper claims are scanned for clean and clear data recording. To get the best results, paper claims must be legible and submitted in the proper format. Follow these requirements to speed processing and prevent delays: Use the correct form and be sure the form meets Centers for Medicare and Medicaid Services standards. Use black or blue ink (do not use red ink, as the scanner may not be able to read it). Use the “remarks” field for messages. Do not stamp or write over boxes on the claim form. Send the original claim form to Anthem, and retain a copy for your records. Do NOT staple original claims together; Anthem will consider the second claim as an attachment and not an original claim to be processed separately. Remove all perforated sides from the form; leave a ¼-inch border on the left and right side of the form after removing perforated sides. This helps our scanning equipment scan accurately. Type information within the designated field. Be sure the type falls completely within the text space and is properly aligned. Don't highlight any fields on the claim forms or attachments; doing so makes it more difficult to create a clear electronic copy when scanned. If using a dot matrix printer, do not use “draft mode” since the characters generally do not have enough distinction and clarity for the optical scanner to read accurately. If you submit paper claims, you must include the following Provider information: Provider name Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 102 Chapter 9: Claims and Billing Rendering Provider Group or Billing Provider Federal Provider Tax Identification Number (TIN) The Anthem Payer Identification Number National Provider Identifier (NPI) Medicare number (if applicable) Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Please Note: Some claims may require additional attachments. Be sure to include all supporting documentation when submitting your claim. Claims with attachments should be submitted on paper. Mail paper claims to: Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 Claims & Billing Paper Claims Processing All submitted paper claims are assigned a unique Document Control Number (DCN). The DCN identifies and tracks claims as they move through the claims processing system. This number contains the Julian date, which indicates the date the claim was received. Document Control Numbers are composed of 11 digits: 2-digit plan year 3-digit Julian date 2-digit Anthem reel identification 4-digit sequential number Claims entering the system are processed on a line-by-line basis except for inpatient claims, which are processed on a whole-claim basis. Each claim is subjected to a comprehensive series of checkpoints called “edits.” These edits verify and validate all claim information to determine if the claim should be paid, denied or pended for manual review. The Provider is responsible for all claims submitted with the Provider number, regardless of who completed the claim. If you use a billing service you must help ensure that your claims are submitted properly. Claims & Billing Member Copayments and Balance Billing Providers contracted with Anthem may not “balance bill” our Members, which means that Members cannot be charged for covered services above the amount Anthem pays to the Provider. Providers may only bill Members for copayments if a copay applies. Member copays are identified on the Anthem ID Card for Healthy Indiana Plan Members. Out-of-network Providers and non-Indiana Health Coverage Program (IHCP) registered Providers may not balance bill Members. Following state requirements, Providers are to enroll in the IHCP to receive reimbursement for providing services to our Members. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 103 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan An IHCP Provider may bill a Member only when the following conditions have been met: The service is non-covered or the Member has exceeded the program limitations The Member understands, before receiving the service, that the service is not covered and that the Member is responsible for the charges associated with the service The Provider documents that the Member voluntarily chose to receive the service, and that the Member was informed prior to receiving the service that he or she was receiving a non-covered service Please Note: A generic consent form is not acceptable unless it identifies the specific procedure to be performed, and the Member signs the consent before receiving the service. See the Indiana Health Coverage Programs Provider Manual for more information at: http://provider.indianamedicaid.com/, select Manuals. Providers may balance bill a Member when prior authorization of a covered service is denied; however, the Provider must establish and demonstrate compliance with the following procedures: Establish that authorization was requested and denied prior to rendering service. Request to review Anthem's authorization decision. Notify the Member that the service requires prior authorization and that Anthem has denied authorization. If out-of-network, the Provider must also explain to the Member that covered services may be available without cost when provided by an in-network Provider. In such cases, authorization of service will still be required. Inform the Member of his or her right to file an appeal if he or she disagrees with the decision to deny authorization. The Member must be informed of his or her responsibility for payment for receiving non-authorized services. If the Provider chooses to use a waiver to establish Member responsibility for payment, the waiver must meet the following requirements: The waiver is signed only after the Member receives appropriate notification The waiver does not contain any language or condition to the effect that if authorization is denied, the Member is responsible for payment Providers may not use non-specific patient waivers; a waiver must be obtained for each encounter or Member visit that falls under the scenario of non-covered services The waiver must specify the date services are provided and the services that fall under the waiver's application The Provider has the right to appeal any denial of Anthem payment resulting from a denial of authorization. POWER Account funds cannot be used for Member copayments, except under certain circumstances. Please Note: Hospital Providers are required to hold Members liable for the emergency services copayment. The required co-pay amount is listed on the Member's Anthem ID card. Non-caretaker Members (those without children) must always pay $25 unless they are admitted from the ER. The copay may be waived for non-caretaker Members for true emergencies. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 104 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Claims & Billing Cost-Sharing If a Healthy Indiana Plan Member's health care costs exceed 5% of the family's income, Hospital Emergency Departments are required to reduce or waive Member copayments. The Provider notification process is as follows: Providers will be notified, either by the State of Indiana or Anthem, if a Member has exceeded the 5% cap. This notification will include the time period during which the Member’s copayments will be reduced or waived. The accumulated amount that determines if the Member has exceeded 5% of the family’s income during a monthly or quarterly period is based on family health care-related expenses, including POWER Account contributions, premiums, copayments and co-insurance. Claims & Billing Coordination of Benefits Anthem may coordinate Hoosier Healthwise benefits with any other health care program that covers our Members, including Medicare. Indicate “Other Coverage” information on the appropriate claim form. If there is a need to coordinate benefits, include at least one of the following items from the other health care program when submitting a Coordination of Benefits (COB) claim: Third Party Remittance Advice (RA) Third party letter explaining either the denial of coverage or reimbursement COB claims received without at least one of these items will be mailed back to you with a request to submit to the other health care program first. Please make sure that the information you submit explains all coding listed on the other carrier’s RA or letter. We cannot process the claim without this specific information. Anthem must receive COB claims within 90 days from the date on the other program’s RA or letter of denial of coverage. Please Note: For Healthy Indiana Plan, there is no coordination of benefits. Members are not allowed to have other health care coverage. Claims & Billing Claims Filed With Wrong Plan If you file a claim with the wrong insurance carrier, Anthem will process your claim without denying it for failure to file within the filing time limits if: There is documentation verifying that the claim was initially filed in a timely manner The corrected claim was filed within 180 days of the date of the other carrier’s denial letter or Remittance Advice (RA) form Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 105 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Claims & Billing Payment of Claims Once we receive a claim, the following steps are taken: 1. Anthem's processing systems analyze and validate the claim for Member eligibility, covered services and proper formatting. 2. Anthem's processing systems validate billing, rendering and referring Provider information against Anthem and IHCP files. 3. Anthem's processing systems validate against processing rules such as requirement for referral, Prior Authorization or NDC and McKesson ClaimsXten Correct Coding rules. 4. Medical review is performed, as necessary. 5. If no payment is warranted, Anthem sends a Claims Disposition Notice to the Provider with the specific claims processing information. 6. Anthem systems reference Groupers, Pricers and Fee Schedules based on the type of claim to determine pricing. Anthem will finalize a clean electronic claim within 21 calendar days from the date the claim is received. Clean paper claims are paid within 30 calendar days. Anthem will pay interest on clean claims not decided within these times frames. The interest rate is established annually based on the Indiana State Auditor's Report and set by the Indiana Department of Insurance. Claims & Billing Monitoring Submitted Claims Claims status can be monitored by doing the following: Monitor claim status online via Availity: www.Availity.com Monitor claim status through the Interactive Voice Response (IVR) Correct any errors and resubmit immediately to prevent denials due to late filing Please Note: The Interactive Voice Response (IVR) accepts either your National Provider Identifier (NPI) or your Federal Tax Identification Number (TIN) for Provider ID. Should the system not accept those numbers, it will redirect your call to the Anthem Provider Helpline. For purposes of assisting you, we may ask again for your TIN. Interactive Voice Response: 1-800-345-4344 Claims & Billing Electronic Remittance Advice Anthem offers secure electronic delivery of remittance advices, which explain claims in their final status. For more information on electronic remittances, Providers and vendors may call the Anthem EDI Solutions Helpdesk at1-800-470-9630. Claims & Billing Electronic Funds Transfer Anthem allows Electronic Funds Transfer (EFT) for claims payment transactions. This means that claims payments can be deposited directly into a previously selected bank account. You can enroll in this Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 106 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan service by completing the EFT application attached to the first paper remittance advice received each month. Or, you can contact us online at: [email protected]. Claims & Billing Claims Overpayment Recovery Procedure Anthem seeks recovery of all excess claims payments from the person or entity to whom the benefit check is made payable. When an overpayment is discovered, Anthem initiates the overpayment recovery process by sending written notification. If you are notified by Anthem of an overpayment, or discover that you have been overpaid, mail the check, along with a copy of the notification or other supporting documentation within 30 days to the appropriate address: For Hoosier Healthwise or Healthy Indiana Plan Attn: Overpayment Recovery Anthem Blue Cross and Blue Shield P.O. Box 92420 Cleveland, OH 44193-1177 The address above cannot accept overnight packages. For overnight delivery, please use the following address: Attn: Overpayment Recovery Anthem Blue Cross and Blue Shield Lockbox 92420 4100 West 150th Street Cleveland OH 44135 If you believe the overpayment notification was created in error, you should contact Anthem's Cost Containment Department in writing or by phone at: 1-800-345-7029. For claims re-evaluation, send your correspondence to the address indicated on the overpayment notice. If Anthem does not hear from you or receive payment within 45 days, the overpayment amount is deducted from your future claims payments. In cases where Anthem determines that recovery is not feasible, the overpayment is referred to a collection service. Claims & Billing Third Party Recovery Providers may not interfere with or place any liens upon the state’s right or Anthem’s right, acting as the state’s agent, to recovery from third party billing. Claims & Billing Hospital Readmissions Policy A readmission is defined as a hospital admission within 3 days following a previous hospital admission and discharge for the same or related condition. Readmissions greater than 3 days following a previous hospital discharge are treated as separate stays for payment purposes, but are subject to medical review. Claims & Billing Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 107 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Claims Returned for Additional Information Anthem will send you a request for additional or corrected information when the claim cannot be processed due to incomplete, missing or incorrect information. The request includes a form that allows you to return the requested information in an easy-to-follow format. We call this a “Claim Follow-Up Form/Corrected Claim." This form must be returned with the requested information in order to process the claim. Anthem may also request additional information retroactively for a claim that has already been paid. The Claim Follow-Up Form/Corrected Claim also used for these situations. If you receive a request from Anthem for additional information, you must provide it within 30 calendar days from the date of the request or your claim may be denied. To submit additional or corrected information, you should send: A copy of the letter requesting more information All supporting documentation you believe to be important or specifically requested by Anthem Please Note: Many of the claims returned for further information are returned for common billing errors. Claims & Billing Claim Resubmissions When resubmitting a claim, use a Claim Follow-Up Form/Corrected Claim. The resubmission must be received by Anthem within 60 days from the date on the Explanation of Benefits (EOB) or letter with the following information: Complete all required fields as originally submitted and mark the change(s) clearly. Write or stamp "Corrected Claim" across the top of the form. Attach a copy of the EOB and state the reason for re-submission. Send to: Anthem Indiana Medicaid Corrected Claims P.O. Box 6144 Indianapolis, IN 46206-6144 Please Note: Corrected UB-04 (CMS 1450) claims can be sent electronically with the third digit of the type of bill indicating correction or cancel. You can follow-up to determine the status of a claim if there has been no response from Anthem to a submitted claim after 30 business days from the date the claim was submitted. To follow up on a claim, you can: Verify that the claim was not rejected by EDI or returned by mail Call Interactive Voice Response (IVR) at: 1-800-345-4344 Contact the Anthem Provider Helpline at: 1-866-408-6132 (Hoosier Healthwise) 1-800-345-4344 (Healthy Indiana Plan) Check MyAnthem, the secure Provider website at: www.anthem.com. Please Note: Claim search functionality is now available from the online Availity Health Information Network. To register for Availity, take the following steps: 1. Go to www.availity.com Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 108 Chapter 9: Claims and Billing 2. 3. 4. 5. Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Click on Register Now Complete the online registration wizard Print, sign and fax the application You will receive e-mail from Availity with a temporary password and next steps Please note: The Interactive Voice Response (IVR) accepts either your billing National Provider Identifier (NPI) or your Federal Tax Identification Number (TIN) for Provider ID. Should the system not accept those numbers, it will redirect your call to an Anthem Provider Helpline representative who will help you with your question. Claims & Billing Claims Disputes If there is a full or partial claim rejection or the payment is not the amount expected, submit a claims dispute form, called a Provider Dispute /Resolution Request Form. Please refer to the Grievances & Appeals chapter in this manual for more information. Claims & Billing Reference: Covered Services For billing purposes, the following are considered covered services: Ambulance services Audiology services, including hearing aids for adults Behavioral health services, including: o Inpatient and outpatient behavioral/mental health services for children (under age 21) o Outpatient chemical dependency services for children (under age 21) o Detoxification services o Psychiatry services o Counseling services for adults (21 years of age and older) Birthing center services Chiropractic services Dialysis Durable medical equipment and supplies Emergency services Family planning services Home healthcare services Hospital services, including inpatient and outpatient Laboratory Medical Checkups and Comprehensive Care Program (CCP) services for children (under 21) Optometry, glasses and contact lenses, if medically necessary Podiatry Prenatal care Primary care services Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 109 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Radiology, imaging and X-rays Specialist services Therapies – physical, occupational and speech Transplantation of organs and tissues Vision, including optometry and glasses (Hoosier Healthwise only) Claims & Billing Reference: Clinical Submissions Categories The following is a list of claims categories for which we may routinely require submission of clinical information before or after payment of a claim: Claims involving precertification/prior authorization/predetermination (or some other form of utilization review) including but not limited to: o Claims pending for lack of precertification or prior authorization o Claims involving medical necessity or experimental/investigative determinations o Claims involving drugs administered in a physician’s office requiring Prior Authorization Claims requiring certain modifiers Claims involving unlisted codes Claims for which we cannot determine from the face of the claim whether it involves a covered service; thus, benefit determination cannot be made without reviewing medical records, including but not limited to pre-existing condition issues, emergency service-prudent layperson reviews, and specific benefit exclusions Claims for abortion: All abortion claims require review of medical records to determine if the pregnancy is the result of an act of rape or incest. Or, in cases where the woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed Claims that we have reason to believe involve inappropriate (including fraudulent) billing Claims that are the subject of an audit (internal or external), including high-dollar claims Claims for individuals involved in case management or disease management Claims that have been appealed (or that are otherwise the subject of a dispute, including claims being mediated, arbitrated or litigated) Other situations in which clinical information might routinely be requested: Accreditation activities Coordination of benefits Credentialing Quality improvement/assurance efforts Recovery/subrogation Requests relating to underwriting (including but not limited to Member or Provider misrepresentation/fraud reviews and stop-loss coverage issues) Examples provided in each category are for illustrative purposes only and are not meant to represent an exhaustive list within the category. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 110 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Claims & Billing Reference: National Drug Codes – Hoosier Healthwise Providers must include National Drug Codes (NDCs), Unit of Measurement and Quantity of Drug on all Hoosier Healthwise claims that include physician-administered drugs. This applies to drugs dispensed in both professional and institutional outpatient settings. Indiana's Office of Medicaid Policy and Planning (OMPP) requires that Anthem report the National Drug Code information to the OMPP every month. Anthem will deny professional and outpatient institutional claims containing physician-administered drugs for Hoosier Healthwise Members if any of the following elements are missing or invalid: NDCs Unit of Measurement Quantity of Drug Please Note: The NDC is an 11-digit number on the package or container from which medication is administered. Claims & Billing Reference: Claim Forms & Filing Limits Form Type of Service to be Billed Time Limit to File (Refer to Provider contract to confirm) CMS-1500 Claim Form Physician and other professional services: Specific ancillary services including the following: Audiologists Ambulance Ambulatory Surgical Center Dialysis Durable Medical Equipment Diagnostic Imaging Centers Hearing Aid Dispensers Home Infusion Hospice Laboratories Occupational Therapy Orthotics Physical Therapy Prosthetics Skilled Nursing Facility (SNF) Speech Therapy Some Ancillary Providers may use a UMS-1450 if they are ancillary institutional Providers. Ancillary charges by a hospital are considered facility charges. Within 90 days of service date CMS-1450 Claim Form Hospitals, Institutions and Home Health Services Within 90 days of service date (if the Member is an inpatient for longer than 30 days, interim billing is required as described in the Hospital Agreement). Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 111 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Claims & Billing Reference: Other Filing Limits Action Type of Service to be Billed Time Frame Third Party Liability (TPL) or Coordination of Benefits If the claim has TPL or COB or requires submission to a third party before submitting to Anthem, the filing limit starts from the date on the notice from the third party. From date of notice from third party: 90 days for CMS-1500 claims 90 days for CMS-1450 claims Checking Claim Status Providers should not inquire about the status of a specific claim until at least 30 business days after submission. This is generally considered a reasonable time to process a claim. For general claim status inquiries, refer to the weekly Remittance Advice (RA), the Automated Voice Response (AVR) system, or Electronic Data Interchange. After 30 business days from Anthem’s receipt of claim, submit a Follow-Up Request Form. Or, call the Customer Care Center Interactive Voice Response (IVR), or check online via www.availity.com. Claim Follow-Up To submit a corrected claim following Anthem’s request for more information or correction to claim. You must return requested information to Anthem within: 60 days from the date of the request. Provider Dispute To request a claim appeal, send your request in writing to: Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN 46206-6144 Care Management Appeals: Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN 46206-6144 Provider Appeal nd Submit Claims Appeal. This is the 2 step after a claim dispute and is considered a formal appeal. An appeal request must be received by Anthem within 30 days from the date on the claims dispute response. Send to: 60 days from the receipt of Anthem’s Remittance Advice (RA) of notice of action. If Anthem requires addition information, the Provider must return the information to Anthem within 21 days from the date of Anthem’s request. If the information is not received within 21 days, Anthem may close the case. If the appeal deadline falls on a weekend or holiday, the deadline is extended to the next business day. 30 days from the date on the claims dispute response Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN 46206-6144 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 112 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Claims & Billing Reference: Common Reasons for Rejected and Returned Claims Many of the claims returned for further information are returned for common billing errors. Problem Explanation Resolution Member’s ID Number is Incomplete Hoosier Healthwise: Missing the correct Member ID number listed on the state's Hoosier Healthwise card and/or the YRH prefix. Hoosier Healthwise: Use the Member’s Medicaid ID number on the state's Hoosier Healthwise card plus the YRH prefix. Healthy Indiana Plan: Missing the correct Member ID on the Anthem ID card and/or the YRK prefix. Duplicate Claim Submission Healthy Indiana Plan: Use the Anthem ID number listed on the Anthem HIP card plus the YRK prefix. Overlapping service dates for the same service create a question about duplication. List each date of service, line by line, on the claim form. Avoid spanning dates, except for inpatient billing. Claim was submitted to Anthem twice without additional information for consideration. Make sure you read your RAs and CDNs for important claim determination information before resubmitting a claim. Additional information may be needed. A corrected claim needs to be clearly marked as "Corrected" so that we don't process it as a duplicate. Authorization Number Missing/Does Not Match Services The authorization number is missing, or the approved services do not match the services described in the claim. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Confirm the correct Authorization Number is provided on the claim form (CMS-1500 Box 24 and CMS-1450 Box 63) and that approved services match the provided services. Contact UM to revise the service for authorization if changes occur Version 2.2 June 1, 2014 Chapter 9: Page 113 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Problem Explanation Resolution Missing Codes for Required Service Categories Current Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) manuals are used but changes are made to the codes quarterly or annually. Only codes recognized by IHCP can be used, therefore Providers must also check IHCP billing instructions, as well as HCPCS and CPT manuals. Manuals may be purchased at any technical bookstore, through the American Medical Association or the Practice Management Information Corporation. Unlisted Code for Service Some procedures or services do not have a code associated with them, so an unlisted procedure code is used. Make sure all services are coded with the correct codes. Check the codebooks or ask someone in your office who is familiar with coding. Anthem needs a description of the procedure and medical records in order to calculate reimbursement. DME, prosthetic devices, hearing aids or blood products require a manufacturer’s invoice. For drugs/injections, the National Drug Code (NDC) number is required. By Report Code for Service Some procedures or services require additional information. Anthem needs a description of the procedure and medical records to calculate reimbursement. DME, prosthetic devices, hearing aids or blood products require a manufacturer’s invoice. For drugs/injections, the NDC number is required. Unreasonable Numbers Submitted Unreasonable numbers, such as “9999” may appear in the Service Units fields. Make sure to check your claim for accuracy before submitting it. Submitting Batches of Claims Stapling claims together can make the subsequent claims appear to be attachments, rather than individual claims. Make sure each individual claim is clearly identified and not stapled to another claim. Nursing Care Nursing charges are included in the hospital and outpatient care charges. Nursing charges that are billed separately are considered unbundled charges and are not payable. In addition, Anthem will not pay claims using different room rates for the same type of room to adjust for nursing care. Do not submit bills for nursing charges. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 114 Chapter 9: Claims and Billing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Claims & Billing Processes to Resolve Claim Issues Issue Action Claim denied or paid wrong amount due to incorrect billing by provider, OR Resubmitting claim returned for information such as: EOB of primary insurance, itemized bill, medical records, etc… Submit a Claim Follow-Up Form / Corrected Claim. It must be received by Anthem within 60 days from date on the EOB or letter. All required fields are to be completed as originally submitted and the change(s) clearly marked and write or stamp “Corrected Claim” across top of the form, and attach copy of the EOB and state the reason for re-submission. Send to: Anthem Indiana Medicaid Corrected Claims PO Box 6144 Indianapolis, IN 46206-6144 Note that corrected UB claims can be sent electronically with the third digit of the type of bill indicating correction or cancel. Unknown status of claim submitted more than 30 days ago {after verifying not rejected by EDI (electronic) or returned by mail room (paper)}. Call the Anthem Provider Helpline. Follow-up on status of a claim adjustment or reprocessing resulting from: Claim Dispute, Claim Appeal, or Provider Help Line/ Provider Services action. Call the Anthem Provider Helpline. Provider disagrees with full or partial claim rejection OR Submit Claims Dispute. A complete Provider Dispute Resolution Request Form must be received by Anthem within 60 days from date on the EOB. Multiple claims for the same situation can be submitted on one form. Send to: Anthem Indiana Medicaid Claims Dispute PO Box 6144 Indianapolis, IN 46206-6144 Note that it is the provider’s responsibility to check EOBs and submit Claims Disputes timely. Payment is not the amount expected. Hoosier Healthwise: 1-866-408-6132 HIP: 1-800-345-4344 Network providers must file claims within 90 days and it is the provider’s responsibility to follow-up timely to be sure claims are received. Hoosier Healthwise: 1-866-408-6132 HIP: 1-800-345-4344 Allow 60 days for adjustments, but follow-up before 90 days. All follow-up to previous actions or interactions must be within 90 days Provider disagrees with Claims Dispute response. Submit Claims Appeal. nd This is the 2 step after a Claim Dispute and considered a formal appeal. An appeal request must be received by Anthem within 30 days from the date on the Claims Dispute response. Send to: Anthem Indiana Medicaid Claims Appeal PO Box 6144 Indianapolis, IN 46206-6144 Complicated, involved claim issues. Submit Written Correspondence. Send electronically through Availity, or send paper correspondence to: Anthem Indiana Medicaid Correspondence PO Box 6144 Indianapolis, IN 46206-6144 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 9: Page 115 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 10: BILLING PROFESSIONAL & ANCILLARY CLAIMS Hoosier Health Care Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Professional Billing Requirements Overview Providers can depend upon efficient claims handling and faster reimbursement when they follow Anthem’s professional and ancillary billing requirements. These requirements include using standardized codes for most of our health services. This section is broken down into health service categories to help you find the specific billing codes you’ll need for each one. You will also find information on the proper method for filling out the CMS-1500 claim form. To help you navigate the various billing requirements and codes, we’ve divided them into the following service categories: Behavioral Health Emergency Services Hospital Readmission Policy Immunizations Covered by Vaccines for Children (VFC) Immunizations Not Covered by Vaccines for Children Initial Health Assessments Maternity Services Newborns On Call Services Preventive Medicine Services: New Patient Preventive Medicine Services: Established Patient Self-Referable Services For the most efficient claims processing, accurately filled-out claims are essential. Follow these general guidelines for claims filing: Indicate the Provider’s National Provider Identifier (NPI) number in Box 24J of the CMS-1500 form. Missing or invalid numbers may result in nonpayment. Mid-level practitioners should put their NPI number in Box 19 of the CMS-1500 and the supervising Provider’s NPI number in Box 24J. The following types of practitioners are defined as mid-level: Physician Assistants Nurse Practitioners Certified Nurse Midwives Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 10: Page 116 Chapter 10: Billing Professional and Ancillary Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Hoosier Healthwise: Use the alpha prefix YRH along with the 12 digit Member number provided by the State Healthy Indiana Plan: Use the alpha prefix YRK along with the 9 digit Member Anthem ID number Federally Qualified Health Centers (FQHC) may put their billing/group NPI number in Box 24J and 33. Professional Billing Requirements Coding In order to process claims in an orderly and consistent manner, we use standardized codes. The Healthcare Common Procedure Coding System (HCPCS), sometimes referred to as National Codes, provides coding for a wide variety of services. There are two principal coding levels, referred to as Level I and Level II: Level I: Current Procedural Terminology (CPT) codes maintained by the American Medical Association (AMA) o These codes are represented by 5 numeric digits Level II: Codes that identify products, supplies and services not included in the CPT codes, such as ambulance supplies and Durable Medical Equipment (DME) o These are sometimes called the alphanumeric codes because they consist of a single alphabetical letter followed by 4 numeric digits In some cases, 2-digit/character modifier codes should accompany the Level I or Level II coding There are two useful reference guides for coding claims: The Current Procedural Terminology (CPT) manual, published by the American Medical Association. To order, call: 800-621-8335 The Healthcare Common Procedure Coding System (HCPCS) published by the Centers for Medicare and Medicaid Services (CMS). To order, call: 800-621-8335 Please Note: Anthem does not accept global billing codes. If Anthem receives a claim with global coding, it will be returned to you with a mail-back form asking you to re-bill using itemized codes. Providers have 21 calendar days from the date of our request letter to submit the corrected claim, and 120 days from the date of the first denial to appeal. Professional Billing Requirements National Drug Codes Providers must include National Drug Codes (NDCs) on all claims that involve products or services with an NDC. The contractor shall submit this NDC information to the state with its encounter claims submissions in accordance with Section 9.6.2. Professional Billing Requirements Initial Health Assessments Anthem Primary Medical Providers function as a Member’s “medical home.” For that reason, we strongly recommend that an Initial Health Assessment (IHA) consisting of a complete history and physical and preventive services be conducted within the following time frames: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 10: Page 117 Chapter 10: Billing Professional and Ancillary Claims Newborns: within 14 days of enrollment Children: within 60 days of enrollment Adults (18-21): within 8 weeks of enrollment Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan When billing for Initial Health Assessments, use the following International Classification of Diseases (ICD) diagnosis codes: V20.2 for children (newborn to 18 years old) V70.0 for adults (19 years and older) Professional Billing Requirements Preventive Medicine Services: New Patient Preventive medicine services for a new patient start with an initial comprehensive preventive medicine evaluation. That includes an age and gender-appropriate history, examination, counseling, risk factor interventions, and the ordering of appropriate immunizations, laboratory and diagnostic procedures. Bill for these services using the following codes: Code Description 99381 Infant (Under 1 Year) 99382 Early Childhood (Ages 1-4) 99383 Late Childhood (Ages 5-11) 99384 Adolescent (Ages 12-17) 99385 Ages 18-39 Professional Billing Requirements Preventive Medicine Services: Established Patient Preventive medicine services for an established patient involve re-evaluation and management of existing conditions, if any. That includes an age and gender-appropriate history, examination, counseling, risk factor interventions, and the ordering of appropriate immunizations, laboratory and diagnostic procedures. Code Description 99391 Infant (Under 1 Year) 99392 Early Childhood (Ages 1-4) 99393 Late Childhood (Ages 5-11) 99394 Adolescent (Ages 12-17) 99395 Ages 18-39 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 10: Page 118 Chapter 10: Billing Professional and Ancillary Claims 99396 Ages 40-64 99397 Ages 65 and older Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Professional Billing Requirements Self-Referable Services Members may access the following services at any time without pre-authorization or referral by their Primary Medical Provider: Behavioral Health Services (Hoosier Healthwise & Healthy Indiana Plan) o Psychiatric Services: Anthem Members may self-refer to any in-network or IHCP-enrolled Behavioral Health Services psychiatrist. o Behavioral Health Services not given by a psychiatrist: Anthem Members may self-refer to any in-network Behavioral Health Services Provider, including behavioral health, substance abuse and chemical dependency Chiropractic Care (Hoosier Healthwise) Diabetes Self-Care Training (Hoosier Healthwise & Healthy Indiana Plan) Emergency Services (Hoosier Healthwise & Healthy Indiana Plan) Eye & Vision Care, except surgery (Hoosier Healthwise) Family Planning (Hoosier Healthwise & Healthy Indiana Plan) HIV/AIDS Targeted Case Management (Hoosier Healthwise) Podiatry (Hoosier Healthwise & Healthy Indiana Plan) Vaccines (Hoosier Healthwise & Healthy Indiana Plan) Professional Billing Requirements Behavioral Health Behavioral Health Services are provided by Anthem for Hoosier Healthwise and Healthy Indiana Plan Members. All claims for services should be billed to Anthem. For more information, please call: 1-866-398-1922. Anthem Behavioral Health has contracted with a network of hospitals, group practices and independent behavioral health Providers, as well as a number of Indiana’s Community Mental Health Centers (UMHCs) to provide behavioral health services. See Chapter 5: Behavioral Health Services for information about behavioral health benefits. Providers rendering medically necessary behavioral health services should bill Anthem using behavioral health CPT codes. Professional Billing Requirements Emergency & Related Professional Services Emergency services, as defined by state and local law, the Provider contract and our Member Handbook, are reimbursed in accordance with the Anthem Provider contract. Please Note: Authorizations are not required for medically necessary emergency services. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 10: Page 119 Chapter 10: Billing Professional and Ancillary Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan **Emergency: Any condition manifesting itself by acute symptoms of sufficient severity such that a layperson possessing an average knowledge of health and medicine could reasonably expect that the absence of immediate medical care could: Place the Member’s health or, with respect to a pregnant woman, the health of the woman and her unborn child, in serious jeopardy Cause serious impairment to bodily functions Cause serious dysfunction to any bodily organ or part Covered emergency services include: Hospital-based emergency department services (room & ancillary) needed to evaluate or stabilize the emergency medical or behavioral health condition Services by emergency Providers Emergency Services for Healthy Indiana Plan Members ONLY: If a Member receives treatment in a hospital emergency room for a non-emergent condition, a copayment is required. The appropriate copayment is on the Member’s ID card (Healthy Indiana Plan Members only). POWER Account funds cannot be used by the Member to pay the copayment. Emergency Care copayments should be collected in the following manner: Non-Caretaker adult = $25 Adult parents with less than 105% FPL = $3 Anthem will waive or return the copayment if the caretaker is found to have an emergency condition, as defined in section 1867(e)(1)(A) of the Emergency Medical Treatment and Active Labor Act, or if the Member is admitted to the hospital on the same day as the visit. The copayment requirement for caregivers will be waived according to prudent layperson guidelines. If Anthem determines through the claims process that the copayment should not have been charged, and the hospital collected a copayment, you must refund the copayment to the Member. Providers shall not collect co-payments from Healthy Indiana Plan Members for emergency room visits resulting in an inpatient admission. Related professional services offered by Providers during an emergency room visit are reimbursed according to your Anthem Provider contract. Assuming the Member has an available and accessible non-emergency services Provider, and a determination has been made that the Member does not have an emergent condition, the hospital must inform the Member before providing non-emergency services of the following: The hospital may require a copayment before the service can be provided The hospital will provide the name and location of an alternate non-emergency services Provider who is actually available and accessible An alternate Provider can provide the services without a co-payment The hospital will provide a referral to coordinate scheduling of services All Members should be referred back to their Primary Medical Provider for follow-up care. Unless clinically required, follow-up care should never occur in a hospital emergency room. Hospitals will be reimbursed for emergency services billed with codes: 99284 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 10: Page 120 Chapter 10: Billing Professional and Ancillary Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan 99285 Please Note: Hospitals may only bill Revenue Code 451 if the emergency room screening determines that the visit is non-emergent. Hospital reimbursement will be reduced by 40% for services billed with codes: 99281 99282 99283 Professional Billing Requirements Hospital Readmission Policy Anthem does not reimburse for readmission for a related condition if the Member’s readmission occurs within 3 days of discharge. These charges must be added to the original claim. Anthem may require medical records and review readmissions within 30 days of discharge to determine if the Member was discharge early. Based on medical review, readmission within 30 days due to early discharge may be denied. Professional Billing Requirements Immunizations Covered By Vaccines for Children Anthem network Providers who administer vaccines to children 0-18 years of age may enroll in the Vaccines for Children (VFC) program. Anthem will only reimburse the administration fee for any vaccine available through the VFC program. When billing immunizations provided to you by the (VFC) program, use the CMS-1500 form and do the following: On one line of Box 24D, use the appropriate CPT code On another line of Box 24D, use the appropriate administration procedure code (90471 through 90474) In Box 23, insert the Primary Medical Provider name Professional Billing Requirements Immunizations Not Covered By Vaccines for Children When billing for immunizations not covered by the VFC program, use the CMS-1500 form and do the following: On one line of Box 24D, use the appropriate CPT code On another line of Box 24D, use the appropriate administration procedure code The SL modifier is not required Professional Billing Requirements Additional Services during EPSDT Exams If a patient is evaluated and treated for a problem during the same visit as an EPSDT annual exam or Well Child visit, the problem-oriented exam can be billed separately if accompanied by the 25 modifier. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 10: Page 121 Chapter 10: Billing Professional and Ancillary Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The problem must require additional moderate level evaluation to qualify as a separate service on the same date. Professional Billing Requirements Maternity Services Maternity services are not covered by the Healthy Indiana Plan (HIP). A HIP Member who becomes pregnant becomes eligible for Hoosier Healthwise. Pending enrollment in Hoosier Healthwise, nonpregnancy-related services remain covered through the Healthy Indiana Plan until the transfer is complete. Proof of pregnancy must be submitted with a completed "change report" for pregnant HIP Members; this will speed up the transfer to Hoosier Healthwise and the payment of pregnancy claims. The Provider's statement or requested medical documentation of pregnancy must be provided to the Member at no additional charge. When enrollment in Hoosier Healthwise is complete, the pregnant Member will be removed from the Healthy Indiana Plan (HIP) and all of her medical services, pregnancy-related and otherwise, will be covered under Package B of Hoosier Healthwise. She will receive a pro-rated balance of her POWER Account upon leaving the HIP program. Following her pregnancy, the Member may re-enroll in HIP. Anthem will be responsible for helping her with the transitions to ensure seamless coverage. Please Note: A Member transferred in (and out) of the Healthy Indiana Plan will receive a new card when they are moved to a new plan. Professional Billing Requirements Billing Requirement for Pregnancy Services Pregnancy is a covered benefit for Hoosier Healthwise. It is not a covered benefit for the Healthy Indiana Plan. Please refer to the IHCP Manual (Chapter 8) for detailed instructions. Billing requirements for Hoosier Healthwise pregnancy services are also listed in Chapter Eight: Billing Instructions of the Indiana Health Coverage Programs Provider Manual. You can access the state’s manual at http://provider.indianamedicaid.com/ > Manuals. Anthem requires itemization of maternity services when submitting claims for reimbursement. Please use the CMS-1500 claim form with the appropriate CPT and HCPCS codes, along with ICD diagnosis codes. This includes the applicable “Evaluation and Management” (E&M) code, along with coding for all other procedures performed. Maternity billing guidelines are as follows: Anthem reimburses only one delivery or cesarean section procedure per Member in a 7-month period. Reimbursement includes multiple births. Delivering Providers who perform regional anesthesia or nerve block may not receive additional reimbursement because these charges are included in the reimbursement for the delivery. Anthem reimburses anesthesia services and delivery at full allowance when provided by the delivering obstetrician. Anthem will reimburse antepartum care, deliveries including cesarean sections performed by physicians, and postpartum care: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 10: Page 122 Chapter 10: Billing Professional and Ancillary Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Codes 59409, 59514, 59612 and 59620: Vaginal and Cesarean Deliveries Code 59430: Postpartum care only Code 59425: Antepartum care only (2-6 visits) Code 59426: Antepartum care only (7 or more visits) When billing Anthem, you must itemize each service individually and submit claims as the services are rendered. The filing deadline will be applied to each individual date of service submitted. Laboratory (including pregnancy test) and radiology services provided during pregnancy must be billed separately and be received by Anthem within 90 days from the date of service. Use of the appropriate antepartum or postpartum CPT codes is necessary for appropriate reimbursement. You should indicate the estimated date of confinement (EDC) on the CMS-1500 claim form. If a Member is admitted to the hospital during the course of her pregnancy, the diagnosis necessitating the admission should be the primary diagnosis on the claim. If high risk, the high-risk diagnosis must be documented on the claim form. The nature of a high-risk care visit must be identified in the diagnosis field on the CMS-1500 claim form, or the appropriate field. For professional claims only, the date of the Member's last menstrual period must be included. All pregnancy-related claims for Members must include one of the modifiers below to indicate the trimester or diagnosis Code V24 for postpartum: Modifier U1: First Trimester Modifier U2: Second Trimester Modifier U3: Third Trimester Professional Billing Requirements Maternity Services: Claims for Obstetric Deliveries Require a Modifier Claims submitted for obstetric deliveries with procedure codes: 59409, 59410, 59514, 59515, 59612, 59614, 59620, or 59622 will require one of the following modifiers: Modifier Description U1 Medically necessary delivery prior to 39 weeks of gestation U2 Delivery at 39 weeks of gestation or later U3 Non-medically necessary delivery prior to 39 weeks of gestation Claims submitted for antepartum care with procedure Codes 59425 or 59426 require one of the following: Modifier Description U1 Medically necessary delivery prior to 39 weeks of gestation U2 Delivery at 39 weeks of gestation or later U3 Non-medically necessary delivery prior to 39 weeks of gestation Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 10: Page 123 Chapter 10: Billing Professional and Ancillary Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Professional Billing Requirements Maternity Services: Cesarean Sections Medicaid restricts any Cesarean section, labor induction, or any delivery following labor induction to one of the following additional criteria: • Gestational age of the fetus should be determined to be at least 39 weeks or fetal lung maturity must be established before delivery. When the delivery occurs prior to 39 weeks, maternal and/or fetal conditions must dictate medical necessity for the delivery. Cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to 39 weeks of gestation and are not considered medically necessary will be denied. Records will be subject to retrospective review. Payments made for non-medically-indicated Cesarean section, labor induction, or any delivery following labor induction that fails to meet these criteria, (as determined by review of medical documentation) will be subject to claim recoupment. Recoupment may apply to all services related to the delivery, including additional Provider and hospital fees. Professional Billing Requirements Maternity Services: Newborns Submit newborn claims using the state-issued Medicaid ID number of the newborn. Do not use the temporary ID numbers (those ending with NB followed by one or more digits). Anthem rejects claims with temporary ID numbers. You will also need to submit the name, date of birth and other pertinent information about the newborn. To prevent any lapse in Anthem coverage for newborns, please ask your patients to take these important steps as soon as their babies are born: Immediately contact the Indiana Family and Social Services Administration (FSSA) or their social worker to request the required paperwork Fill out and return the required paperwork to the state to enroll their newborn in Medicaid Anthem requests that you notify us of all deliveries within 3 days of delivery. Use the Newborn Enrollment Notification Report found on in the Forms Library of the Provider Resources page on our website at www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Also notify Anthem via the Newborn Enrollment Notification Report referenced above when you receive a newborn’s permanent Medicaid ID number. Hospitals may bill for newborn delivery and other newborn services separately from the claims for services they provide for the mother. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 10: Page 124 Chapter 10: Billing Professional and Ancillary Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Professional Billing Requirements Healthy Indiana Plan Maternity Related Services Providers can be reimbursed from Traditional Medicaid for pregnancy related services that occurred during the time the member was on the Healthy Indiana Plan. Providers must wait until after the member transfers to Hoosier Healthwise. Claims for services during this “discovery period” (up to 3 months prior to transfer to Hoosier Healthwise) may be submitted to HP at this address: HP –HIP Pregnancy Related Claims P.O. Box 7271 Indianapolis, IN 46207 – 7271 Miscarriage / Spontaneous Abortion Before Healthy Indiana Plan Member Transfers to Hoosier Healthwise When a miscarriage occurs before a HIP member has moved to Hoosier Healthwise, the Healthy Indiana Plan will pay the related claims. We will also go back and pay any other pregnancy related claims that had been denied due to the pregnancy exclusion. Providers should contact us through the Provider Helpline or submit a written request when there isn’t a claim submitted for spontaneous abortion or miscarriage to trigger adjustments of previous maternity related claims. Professional Billing Requirements Newborns: Circumcision All circumcisions performed on Members more than 30 days after birth will require authorization from the Plan’s Utilization Management department and will be subject to medical necessity. Professional Billing Requirements On-Call Services On-Call Services can be billed when the rendering physician is not the Primary Medical Provider, but is covering for or has received permission from the Primary Medical Provider to provide service that day. Insert On-Call for Primary Medical Provider on the CMS-1500 claim form. Professional Billing Requirements Working After Normal Business Hours Providers receive additional compensation for services provided after normal business hours. Anthem has established normal business hours for Primary Medical Providers as: Monday-Friday, 8am-5pm For services provided outside of normal business hours, bill CPT code 99050 in addition to the billing codes for services rendered in order to receive additional reimbursement. Professional Billing Requirements Recommended Fields for CMS-1500 All professional Providers and vendors should bill Anthem using the most current version of the UMS1500 claim form. The following guidelines will assist in completing the UMS-1500 form. The letter “M” indicates a mandatory field. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 10: Page 125 Chapter 10: Billing Professional and Ancillary Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan For more information, you may also refer to the Centers for Medicare and Medicaid Services website at: www.cms.hhs.gov/cmsforms/. Member ID Number Use the Member's Anthem ID number, including alpha prefixes: Hoosier Healthwise: YRH Healthy Indiana Plan: YRK Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 10: Page 126 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 11: BILLING INSTITUTIONAL CLAIMS Hoosier Health Care Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Billing Institutional Claims Overview Billing for hospitals and other health care facilities and services can require special attention because major services have their own set of billing requirements. Throughout this section, specific billing requirements will be broken down into the following service areas: Emergency Room Visits Urgent Care Visits Maternity Termination of Pregnancy Inpatient Acute Care Hospital Stays of Less Than 24 Hours Inpatient Sub-Acute Care Outpatient Laboratory, Radiology and Diagnostic Services Outpatient Surgical Services Outpatient Therapies Outpatient Infusion Therapy Visits and Pharmaceuticals Also included are helpful billing guidelines for the ancillary services Providers use most often, including diagnostic imaging. Ancillary services include the following: Ambulance Services Ambulatory Surgical Centers Dialysis Durable Medical Equipment Home Health Care Home Infusion Therapy Hospice Laboratory and Diagnostic Imaging Physical, Speech and Occupational Therapy Skilled Nursing Facilities Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 127 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Please Note: A Member’s benefits may not cover some of these services; you must confirm coverage before providing service. And finally, this section will take a look at specific coding guidelines for the standard hospital and health care facilities claim form, the CMS-1450. Billing Institutional Claims Basic Billing Guidelines In general, here are the basic billing guidelines you’ll need for institutional claims submitted to Anthem: Use HCPCS, CPT or Revenue Codes: Valid HCPCS, CPT or revenue codes are required for all line items billed, whether sent on paper or electronically. Split Year-End Claims: Services that begin before or in December and extend beyond December 31st should be billed as a split claim at calendar year end. Two CMS-1500 forms must be used and must be submitted together. Split Dates of Service for a Provider Contract Change: When a Provider contract change occurs during the course of treatment, split the dates of service in order to be reimbursed at the new rate. Itemize Services: Service itemization is required when the “From” and “Through” service dates are the same. Provide Medical Records: Medical records for certain procedures may be requested for determination of medical necessity. Use Modifiers: Use modifiers in accordance with your specific billing instructions. Use Codes for Unlisted Procedures: Some Provider services or procedures are not found in CPT; therefore, specific code numbers for reporting unlisted procedures have been designated. When an unlisted procedure code is used, will need a description of the service in order to calculate the appropriate reimbursement. Medical records may be requested. Do Not Use CPT Code 99070: This code, for supplies and materials provided over and above those usually included with an office visit or other services, is not accepted by Anthem. Health care Providers must use HCPCS Level II Codes, which give a detailed description of the service provided. Anthem will pay for surgical trays only for specific surgical procedures. Surgical trays billed with all other services will be considered incidental and will not be paid separately. Please Note: System edits are in place for both electronic and paper claims. Claims submitted improperly cannot be easily processed and will most likely be returned. Billing Institutional Claims National Drug Codes – Hoosier Healthwise Providers must include National Drug Codes (NDCs), Unit of Measurement and Quantity of Drug on all Hoosier Healthwise claims that include physician-administered drugs. This applies to drugs dispensed in both professional and institutional outpatient settings. Indiana's Office of Medicaid Policy and Planning (OMPP) requires that Anthem report the National Drug Code information to the OMPP every month. The Indiana Health Coverage Programs (IHCP) submits this data to pharmaceutical manufacturers in order to obtain rebates under the Medicaid Drug Rebate Program. It is important to follow these instructions so that the state receives timely Medicaid Drug Rebates from drug manufacturers. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 128 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Anthem will deny professional and outpatient institutional claims containing physician-administered drugs for Hoosier Healthwise Members if any of the following elements are missing or invalid: NDCs Unit of Measurement Quantity of Drug Please Note: The NDC is an 11-digit number on the package or container from which medication is administered. Billing Institutional Claims Billing Requirements by Service Category: Emergency Room Visits The billing requirements for an emergency room visit apply to the initial treatment of a medical or psychiatric emergency, but only if the patient does not remain overnight. If the emergency room visit results in an admission, then all services provided in the emergency room must be billed in conformity with the guidelines and requirements for inpatient acute care. Reimbursement for emergency room services relates to the nature of the emergency diagnosis and can be based on urgent care rates, depending on the diagnosis. The billing requirements for emergency room treatment cover all diagnostic and therapeutic services, including, but not limited to: Equipment Facility use (including nursing care) Laboratory Pharmaceuticals Radiology Supplies Other services incidental to the emergency room visit Anthem will not reimburse Providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition. There are two exceptions to this requirement: Anthem will reimburse the physician screening fee and facility fee, even If the condition is not an emergency Anthem will reimburse if the services were authorized by Anthem or if the Primary Medical Physician referred the Member for treatment Anthem will review Hoosier Healthwise and Healthy Indiana Plan emergency services claims to determine appropriate use of the emergency room and whether an emergency medical condition existed. At a minimum, both the facility and the physician will receive reimbursement for screening services: For physician services billed on a CMS-1500 claim: If a prudent layperson review determines that the service was not an emergency, Anthem is required to reimburse, at minimum, for Current Procedural Terminology (CPT) code 99281, the Emergency Department Visit Level 1 screening fee. For facility charges billed on a UB-04: If a prudent layperson review determines the service was not an emergency, we must reimburse for revenue code 451, EMTALA Emergency Medical Screening Services. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 129 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Special emergency room billing instructions and requirements: Specific coding is required for emergency room billing. Use the following guidelines, including: Bill each service date as a separate line item. Members should receive screening examination regardless of payment of copay No ER copay is necessary if the patient is admitted; the ER copay only applies to non-emergent services provided in an ER setting Use CPT codes 99284 or 99285 for emergency room billing. Use ICD principal diagnosis codes, as required, for all services provided in an emergency room setting. Use revenue codes 0450-0452, and 0459, as required. Services billed with CPT codes 99281, 99282 and 99283 will be reduced by 40% as non-emergent services. Please Note: Unless clinically required, follow-up care should never occur in the emergency department. Members should be referred back to their Primary Medical Provider and correct billing should follow standard, non-emergency guidelines. Billing Institutional Claims Billing Requirements by Service Category: Urgent Care Visits The billing requirements for urgent care visits apply to all urgent care cases treated and discharged from the hospital outpatient department or emergency room. **Urgent Care: Non-scheduled, non-emergency hospital services required to prevent serious deterioration of a patient’s health as a result of an unforeseen illness or injury. Urgent care billing should detail all diagnostic and therapeutic services including, but not limited to: Equipment Facility use (including nursing care) Laboratory Pharmaceuticals Radiology Supplies Other services incidental to the visit Urgent care visits do not apply to those cases that are admitted and treated for inpatient care following urgent care treatment. Special urgent care billing instructions: Specific coding is required for urgent care billing. Use the following guidelines, including: Bill each service date as a separate line item. Use current ICD-9/ICD-10 principal diagnosis codes, as required, for all services provided in an urgent care setting or designated facility. Use the required CPT codes: 99281-83. Use the required revenue codes: 045X, 0516, 0526, 0700, 072X. Use billing code 99050 for after-hours care. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 130 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Please Note: If the Member is admitted following urgent care, then the entire billing requirement shifts to acute or sub-acute care. Billing Institutional Claims Billing Requirements by Service Category: Maternity The billing requirements for maternity care apply to all live and stillbirth deliveries. They include payment for services including, but not limited to: Room and board for mother (including nursing care) Nursery for baby (including nursing care) Delivery room/Surgical suites Equipment Laboratory Pharmaceuticals Radiology Other services incidental to admission The maternity care rate covers the entire admission, except for admissions approved for extension beyond the contracted time limit for continuous inpatient days. In such cases, the billing requirements for the entire admission shifts to those for inpatient acute care (later in this section) for each approved and medically necessary service day. Therapeutic abortions, treatment for ectopic and molar pregnancies and similar conditions are excluded from payment under this rate. Billing Institutional Claims Billing Requirements by Service Category: Inpatient Acute Care The billing requirements for inpatient acute care apply to each approved and medically necessary service day in a licensed bed. They include, but are not limited to: Room and board (including nursing care) Emergency room (if connected to admission) Urgent care (if connected to admission) Equipment Laboratory Pharmaceuticals Radiology Supplies Surgery and recovery suites Other services incidental to the admission Prior authorization is required for all admissions except standard vaginal delivery and Cesarean sections. Special billing instructions and requirements: Must be an Indiana Health Coverage Programs (IHCP) facility Utilization Management approval is required for all admissions, except routine deliveries Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 131 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Billing observation room or outpatient charges with an inpatient stay: o The dates reported on the CMS 1450 form in the “From” box of Form Locator 6 (FL 6) and Form Locator 17 (FL 17) should be the same. These charges should also reflect the date the patient was admitted as an inpatient to the hospital. o Using the “From” box of (FL 6) and (FL 17) to reflect the date of an observation stay or outpatient charges that may have occurred prior to inpatient admission is incorrect and may cause processing delays. Billing Institutional Claims Billing Requirements by Service Category: Hospital Stays of Less Than 24 Hours When submitting claims for hospital stays of less than 24 hours, bill the claim as an Outpatient Hospital Services claim and follow these guidelines: Service Codes: Include the correct CPT/HCPCS codes for each service Line Items: Bill each service for each date as separate line items Revenue Codes: Bill the revenue codes with the appropriate CPT/HCPCS codes Type of Bill: Type of bill field entry must be 13X Claims denied for a stay of less than 24 hours are claims that have the same admit and discharge date, or have a discharge date of the day after admission. Patients who are transferred out within 24 hours of admission should be billed as outpatient claims. Please Note: This does not apply to neonatal claims, which are expressly one-day stays that fall under the following Diagnosis-Related Groups (DRGs): DRG 637 – Neonate, died within 1 day of birth, born here DRG 638 - Neonate, died within 1 day of birth, not born here DRG 639 - Neonate, transferred less than 5 days old, born here DRG 640 - Neonate, transferred less than 5 days old, not born here Inpatient claims with next day discharge are assumed to be less than 24 hours if medical records are not provided. Claims submitted for inpatient stays with the "though date" of service one day later than the "from date" of service will be subject to post payment review. Billing Institutional Claims Billing Requirements by Service Category: Inpatient Sub-Acute Care The billing requirements for inpatient sub-acute care include each approved and medically necessary service day in a licensed and accredited facility at the appropriate level of care. **Sub-Acute Care: Includes levels of inpatient care less intensive than those required in an inpatient acute care setting. Each inpatient sub-acute care admission is considered a separate admission from any preceding or subsequent acute care admission, and should be billed separately. Covered services include, but are not limited to: Room and board (including nursing care) Equipment Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 132 Chapter 11: Billing Institutional Claims Laboratory Pharmaceuticals Radiology Supplies Other services incidental to the admission Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Please note: All sub-acute admissions require prior authorization and a treatment plan. The treatment plan must accompany the admission and include: Functional, reasonable, objective and measurable goals within a predictable time frame for each skilled discipline A discharge plan and options that are individually customized and identified from the admission date, and that are carried forward from the admission date Weekly summaries for each discipline, and bi-weekly conference reports Billing Institutional Claims Billing Requirements by Service Category: Outpatient Laboratory, Radiology and Diagnostic Services There are specific billing requirements for outpatient laboratory, pathology, radiology and other diagnostic tests. These include billing for services related to the diagnostic tests, including, but not limited to: Facility use Nursing care (including incremental nursing) Equipment Professional services Specified supplies and all other services incidental to the outpatient visit Please note: Outpatient radiation therapy is excluded from this service category and should be billed under the requirements of the Other Services category (later in this chapter). Billing Institutional Claims Billing Requirements by Service Category: Outpatient Surgical Services There are specific billing requirements for outpatient surgical services. The billing requirements include, but are not limited to: Facility use (including nursing care) Blood Equipment Imaging services Implantable prostheses Laboratory Pharmaceutical Radiology Supplies Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 133 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan All other services incidental to the outpatient surgery visit Please note: Even if a service is classified by the hospital as an outpatient service, if the Member is receiving that service as of 12am, it should be billed at the Inpatient Diagnostic Relating Grouping (DRG) rate. Special outpatient surgical services billing instructions: Specific dates, codes and medical records may be required for billing: Follow the billing requirements for outpatient surgery when the respiratory therapy department performs an ECG, EEG or EKG; do not apply the outpatient therapy billing requirements. Include service dates for each procedure (both principal and other). Include CPT/HCPCS codes for each surgical procedure in form locators 44 (HCPCS/RATES). Provide medical records when Anthem needs to review and determine the correct grouping for services not defined in the surgery grouping. Use billing field entry 13X. Use revenue codes 036X, 0480, 0481, 0490, 070X, 071X, 075X, 076X, 079X and 0975, as required, with the appropriate CPT/HCPCS code. Use the CPT/HCPCS code, as mandated by the HIPAA, for outpatient surgery billing. Billing Institutional Claims Billing Requirements by Service Category: Outpatient Therapies Outpatient therapy services include physical, occupational, speech and respiratory therapies. An outpatient therapy visit means a single service date. Billing requirements for these visits include, but are not limited to: Facility use (including nursing care) Therapist/professional services Equipment Pharmaceuticals Supplies Other services incidental to the outpatient therapy visit Special outpatient therapies billing instructions: There are specific requirements for billing outpatient therapies, including: Bill each service date as a separate line item. Use the required revenue codes, including: Occupational therapy = 043X Physical therapy = 042X Respiratory therapy = 041X Speech Therapy = 044X Use the applicable CPT/HCPCS codes, as required. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 134 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Billing Institutional Claims Billing Requirements by Service Category: Outpatient Infusion Therapies and Pharmaceuticals Outpatient Infusion Therapies Billing requirements for outpatient infusion therapy visits apply to each outpatient hospital visit and include, but are not limited to: Facility use (including nursing care) Equipment Intravenous solutions (excluding pharmaceuticals) Kinetic dosing Laboratory Professional services Radiology Supplies (including syringes, tubing, line insertion kits, etc.) Other services incidental to the outpatient infusion therapy visit Outpatient Infusion Pharmaceuticals These billing requirements apply to drugs such as chemotherapy, hydration and antibiotics used during each outpatient infusion therapy visit. One important exception is for blood and blood products, which are billed under “other services.” Special outpatient infusion pharmaceuticals billing instructions: Specific codes and service dates are required, including: Use revenue codes 026X, 028X, 0331, 0335 or 0940, as required, for each outpatient infusion therapy visit. Use revenue code 0940 or 0949 with 36511-36513, 36515-36516 or 36522 CPT/HCPCS codes when billing for therapeutic aphaeresis claims. List each drug for each visit as a separate line item and include the service date. Use HCPCS codes, as required, for all pharmaceuticals when: Billed with revenue codes 0250-0252, 0256-0259, or 063X; you must include the units with pharmaceutical CPT/HCPCS codes Billed with revenue codes 026X, 028X, 0331, 0335, 0940 When using an unlisted CPT/HCPCS code, provide the name of the drug or medication in Box 43 of the CMS-1450 claim form. Billing Institutional Claims Ancillary Billing: Overview Hoosier Healthwise and the Healthy Indiana Plan follow ancillary billing guidelines as outlined in the state of Indiana provider manuals at: http://provider.indianamedicaid.com/general-provider-services/manuals.aspx. Most ancillary claims are submitted for laboratory/diagnostic imaging or Durable Medical Equipment (DME). This section will provide special billing requirements for each. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 135 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Please Note: The Member’s benefits may not cover some of the services listed. Please confirm benefit coverage. Billing Institutional Claims Ancillary Billing Requirements by Service Category: Ambulance Services Ambulance Providers, including municipalities, should use the CMS-1500 form to bill for ambulance services. Use the appropriate 2-digit origin and destination codes that describe the “to” and “from” locations. Billing Institutional Claims Ancillary Billing Requirements by Service Category: Ambulatory Surgical Centers Most outpatient surgery delivered in an ambulatory surgery center requires Prior Authorization. Ambulatory surgical centers bill on the CMS-1500 form. Billing Institutional Claims Ancillary Billing Requirements by Service Category: Physical Therapy The physical therapy setting determines the correct billing form: Form CMS-1500: When providing services in an office, clinic or outpatient setting Form CMS-1450: When providing services in a rehabilitation center Form UB-04: For physical therapists affiliated with home health agencies, providing services in a patient’s home All physical therapy requires Prior Authorization. Contact Anthem’s Utilization Management (UM) department for authorization prior to delivery of services. Billing Institutional Claims Ancillary Billing Requirements by Service Category: Speech Therapy The speech therapy setting determines the correct billing form: Form CMS-1500: When providing services in an office, clinic or outpatient setting Form UB-04: For speech therapists affiliated with home health agencies, providing services in a patient’s home Billing Institutional Claims Ancillary Billing Requirements by Service Category: Occupational Therapy The occupational therapy setting determines the correct billing form: Form CMS-1500: When providing services in an office, clinic or outpatient setting Form UB-04: For occupational therapists affiliated with home health agencies, providing services in a patient’s home Billing Institutional Claims Ancillary Billing Requirements by Service Category: Durable Medical Equipment Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 136 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Billing for custom-made Durable Medical Equipment (DME), prescribed to preserve bodily functions or prevent disability, requires Prior Authorization. Without such review, claims for DME will be denied. Prior to dispensing, please contact Anthem’s Utilization Management (UM) department. Please note: The presence of a Healthcare Common Procedure Coding System (HCPCS) code does not necessarily mean that the benefit is covered or that payment will be made. Some DME codes may be By Report (customized) and therefore require additional information for pre-service review and processing. Special Guidelines for Durable Medical Equipment Billing: Durable Medical Equipment billing requires a differentiation between rentals and purchased equipment. It also requires specific codes and modifiers. Use the appropriate modifier to identify rentals versus purchases (new or used). Claims submitted without the right modifier will be reimbursed at the rental rate. Use HCPCS codes for DME or supplies. Use an unlisted or miscellaneous code (such as E1399) when an HCPCS code doesn’t exist for a particular item of equipment. Use valid codes for DME and supplies; unlisted codes will not be accepted if valid HCPCS codes exist. Attach the manufacturer’s invoice to the claim if using a miscellaneous or unlisted code. The invoice must be from the manufacturer, not the office making the purchase. Please Note: Catalog pages are not acceptable as a manufacturer’s invoice. Billing Institutional Claims Ancillary Billing Requirements by Service Category: DME Rentals Most DME is dispensed on a rental basis. These rentals require medical documentation from the prescribing Provider. Rented items remain the property of the DME Provider until the purchase price is reached. Charges for rentals exceeding the reasonable charge for a purchase are not accepted, and rental extensions may be obtained only on approved items. Please Note: DME Providers should use normal equipment collection guidelines. Anthem is not responsible for equipment not returned by Members. Billing Institutional Claims Ancillary Billing Requirements by Service Category: DME Purchase DME may be reimbursed on a rent-to-own basis over a period of 10 months, unless otherwise specified at the time of review by our Utilization Management department. Billing Institutional Claims Ancillary Billing Requirements by Service Category: DME Wheelchairs/Wheeled Mobility Aids At Anthem, we follow Medicaid guidelines for calculating By Report (customized) wheelchair claims. Claims must include the following: Catalog number Item description Manufacturer’s name Model number Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 137 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Each catalog page or invoice line must be marked so it can be matched to the appropriate claim line. Also, the Reserved for Local Use field (Box 19) on the CMS-1500 form must be filled in with the total MSRP of the wheelchair, including: Accessories Modifications or replacement parts Name of the employed Rehabilitation and Assistive Technology of America (RESNA) certified technician For wheeled mobility aids, there is one additional requirement: The invoice must be an amount published by the manufacturer before August 1, 2003. If the item was not available before then, you must list the date of availability in the Reserved for Local Use field (Box 19) of the UMS-1500 claim form. The catalog page where the item was first published must be attached to the claim. If you are a wheelchair manufacturer billing as a Provider, your billing must include: The MSRP from a catalog page dated before August 1, 2003 If the item was not available before that date, the manufacturer’s invoice must accompany the claim The initial date of availability must be documented in the Reserved for Local Use field (Box 19) of the CMS-1500 claim form Billing Institutional Claims Ancillary Billing Requirements by Service Category: Dialysis Dialysis centers and other entities performing dialysis should use the CMS-1450 form to bill for dialysis services. All dialysis care must be pre-authorized (except where Medicare is the primary payer). Contact Anthem’s Utilization Management (UM) department for authorization prior to delivery of service. Billing Institutional Claims Ancillary Billing Requirements by Service Category: Home Infusion Therapy Home infusion therapy requires Prior Authorization. When billing for home infusion therapy, use the CMS-1500 form and follow these guidelines: Get Prior Authorization, as required, from Anthem’s Utilization Management (UM) department for all infusion therapy. Submit all claims within the contracted filing limit. Use the appropriate HCPCS injection codes to bill for all injections. Use HCPCS code J3490 along with the National Drug Code (NDC) for billing injections only if an appropriate injection code is not found. Please Note: By Report HCPCS codes, including HCPCS code A9999 for supplies and accessories, are reimbursed at the lesser of the amount billed or the manufacturer’s purchase invoice amount, plus a 24% mark-up. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 138 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Billing Institutional Claims Ancillary Billing Requirements by Service Category: Laboratory and Diagnostic Imaging For laboratory and diagnostic imaging, use the CMS-1500 form and refer to the basic billing guidelines found in the beginning (Overview) of this segment, Billing Institutional Claims. Billing Institutional Claims Ancillary Billing Requirements by Service Category: Skilled Nursing Facilities All skilled nursing facility care requires Prior Authorization. Contact Anthem’s Utilization Management (UM) department for authorization prior to SNF admission and bill using the CMS-1450 form. Use codes: 0550-52, 0559, 90300-903XX. Billing Institutional Claims Ancillary Billing Requirements by Service Category: Home Health Care All home health care must be pre-authorized. Contact Anthem’s Utilization Management (UM) department for authorization prior to delivery of service. When billing for a home health care visit, use the CMS-1450 form. Please Note: When billing for supplies and equipment used in a home health care visit, please refer to the Durable Medical Equipment section (earlier in this chapter) for billing requirements. Billing Institutional Claims Ancillary Billing Requirements by Service Category: Hospice Hospice services require Prior Authorization. Contact Anthem’s Utilization Management (UM) department for authorization prior to hospice admission and bill for services on the CMS-1450 form. Billing Institutional Claims Additional Billing Resources The following reference books provide detailed instructions on uniform billing requirements: Current Procedural Terminology (CPT), published by the American Medical Association Healthcare Common Procedure Coding System (HCPCS), National Level II (current year) ICD (current edition) Volumes 1,2,3 (current year), published by the Practice Management Information Corporation Billing Institutional Claims Coding Guidelines: The CMS-1450 Claim Form All Medicare-approved facilities should bill Anthem using the most up-to-date version of the CMS-1450 claim form. All fields must be completed using standardized code sets. These code sets are used to ensure that claims are processed in an orderly and consistent manner. The Healthcare Common Procedure Coding System (HCPCS) provides codes for a variety of services and consists of two main subsystems, referred to as Level I and Level II: Level I: Current Procedural Terminology (CPT) codes determined by the American Medical Association (AMA). Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 139 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CPT codes are represented by 5 numeric digits Level II: Other codes that identify products, supplies and services not included in the CPT codes, such as ambulance services and Durable Medical Equipment (DME). These are sometimes called the alphanumeric codes because they consist of a single alphabetical letter followed by 4 numeric digits. In some cases, 2-digit/character modifier codes should accompany the Level I or Level II coding. The CMS-1450 Revenue Codes UMS-1450 revenue codes are required for all institutional claims. Institutional Inpatient Coding For institutional inpatient coding, use the guidelines in the following code manuals: Use current ICD applicable and procedure codes in Boxes 74-74e of the CMS-1450 claim form when the claim indicates that a procedure was performed. Use modifier codes when appropriate; refer to the current edition of the physician’s Current Procedural Terminology manual published by the AMA. Please refer to your Provider’s contract for Diagnostic Related Grouping (DRG) information. Institutional Outpatient Coding For institutional outpatient coding, use the guidelines in the following code manuals: Healthcare Common Procedure Coding System (HCPCS), published by the Centers for Medicare and Medicaid Services (CMS) Current Procedural Terminology (CPT) Codes: refer to the current edition of the physicians’ CPT manual, published by the AMA Please Note: When using an unlisted CPT/HCPCS code, provide the name of the drug or medication in Box 43 of the CMS-1450 claim form. Billing Institutional Claims Recommended Fields for CMS-1450 (UB-04) The following guidelines will assist in completing the CMS-1450 form. "R" indicates a mandatory field. For additional information, please refer to the IHCP Provider Manual website at: http://provider.indianamedicaid.com/general-provider-services/manuals.aspx. Field # Box Title Description 1 (R) Blank Facility name, address, and phone number. 2 Blank Required when the address for payment is different than that of the Billing Provider information located in Field 1. 3a PAT. CNTL # Member’s account number. 3b MED. REC # Member’s record number, which can be up to 20 characters long. 4 (R) TYPE OF BILL Enter the Type of Bill (TOB) code. 5 (R) FED. TAX NO. Enter the provider’s Federal tax ID number Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 140 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Field # Box Title Description 6 (R) STATEMENT COVERS PERIOD “FROM” and “THROUGH” date(s) covered by the claim being submitted 7 Blank Leave blank. 8a–b (R) PATIENT NAME Member’s name. 9a–e (R) PATIENT ADDRESS Complete address (number, street, city, state, Zip code, telephone number). 10 (R) BIRTHDATE Member’s date of birth in MM/DD/YY format. 11 (R) SEX Member’s gender. 12 (R) ADMISSION DATE Member’s admission date to the facility in MM/DD/YY format. 13 (R) ADMISSION HR Member’s admission hour to the facility in military time (00 to 23) format. 14 (R) ADMISSION TYPE Type of admission. 15 (R) ADMISSION SRC Source of admission. 16 (R) DHR Member’s discharge hour from the facility in military time (00 to 23) format. 17 (R) STAT Patient status. 18–28 CONDITION CODES Enter Condition Code (81) X0 – X9. 29 ACDT STATE Accident State. 30 Blank Leave blank. 31–34 (R) OCCURRENCE CODE OCCURRENCE DATE Occurrence code (42) and date, if applicable. 35–36 OCCURRENCE SPAN (CODE, FROM, & THROUGH) Enter dates in MM/DD/YY format. 37 Blank Leave blank. 38 Blank Enter the responsible party name and address, if applicable. 39–41 VALUE CODES (CODE & AMOUNT) Enter value codes, if applicable. 42 (R) REV. CD. Revenue Code. Revenue codes are required for all institutional claims. 43 (R) DESCRIPTION Description of services rendered 44 (R) HCPCS/RATE/HIPPS CODE Enter the accommodation rate per day for inpatient services or HCPCS/CPT code for outpatient services. 45 (R) SERV. DATE Date of services rendered. 46 (R) SERV. UNITS Number/units of occurrence for each line or service being billed. 47 (R) TOTAL CHARGES Total charge for each line of service being billed Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 141 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Field # Box Title Description 48 NON-COVERED CHARGES Enter any non-covered charges. 49 Blank Leave blank. 50 PAYER NAME Payer Identification. Enter any third party payers. 51 (R) HEALTH PLAN ID Leave blank. Assigned by Plan. 52 (R) REL. INFO Release of information certification indicator. 53 ASG BEN. Assignment of benefits certification indicator. 54 PRIOR PAYMENTS Prior payments. 55 EST. AMOUNT DUE Estimated amount due. 56 (R) NPI Enter the NPI number. (Required after May 23, 2007). 57 (R) OTHER PRIV ID Enter the other provider ID. 58 (R) INSURED’S NAME Member’s name. 59 (R) P. REL Patient’s relationship to insured (N/A: Member is the insured). 60 (R) INSURED’S UNIQUE ID For Hoosier Healthwise, use the 12-digit Medicaid ID number (Recipient Identification [RID] Number), along with the YRH prefix. For Healthy Indiana Plan, use the 9-digit Anthem ID number, along with the YRK prefix 61 GROUP NAME Insured group name — enter the name of any other health plan. 62 INSURANCE GROUP NO. Enter the policy number of any other health plan. 63 TREATMENT AUTHORIZATION Authorization number or authorization information must be entered CODES on this field. 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME Name of organization from which the insured obtained the other policy. 66 (R) DX/PROC qualifier Enter the diagnosis and procedure code qualifier (ICD version indicator). 67 (R) DX Principal Diagnosis Codes. Enter the ICD-9/ICD-10 diagnostic codes, if applicable. 67a–q (R) DX Other Diagnostic Codes. Enter the ICD-9/ICD-10 diagnostic codes, if applicable. Indicate POA. 68 Blank Leave blank. 69 ADMIT DX Admission diagnosis code — enter the ICD-9/ICD-10 code. 70a–c PATIENT REASON DX Enter the Member’s reason for this visit, if applicable. 71 PPS CODE Prospective Payment System (PPS) code (not required). 72 ECI External cause of injury code. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan The control number assigned to the original bill. Version 2.2 June 1, 2014 Chapter 11: Page 142 Chapter 11: Billing Institutional Claims Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Field # Box Title Description 73 Blank Leave blank. 74 (R) PRINCIPAL PROCEDURE (CODE/DATE) ICD-9/ICD-10 principal procedure code and dates, if applicable. 74a–e (R) OTHER PROCEDURE (CODE/DATE) Other Procedure Codes. 75 Blank Leave blank. 76 (R) ATTENDING Enter the attending physician’s ID number. (NPI required after May 23, 2007.) 77 (R) OPERATING Enter the provider number if you use a surgical procedure on this form. (NPI required after May 23, 2007.) 78–79 OTHER Enter any other provider numbers, if applicable. (NPI required after May 23, 2007.) 80 REMARKS Use this field to explain special situations. 81a–d (R) CC Enter taxonomy code with qualifier B3. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 11: Page 143 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 12: MEMBER TRANSFERS & DISENROLLMENT Hoosier Healthwise: Anthem Medicaid Provider Helpline Phone: 1-866-408-6132 Anthem Medicaid Provider Helpline Fax: 1-866-408-7087 Hours of Operation: Monday to Friday, 7am-7pm Healthy Indiana Plan: Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Member Transfers & Disenrollment Overview At Anthem, our Members have the freedom to choose their most important link to quality health care: their doctor. We strongly encourage our Members to select a Primary Medical Provider and remain with that Provider because we believe in the positive impact of having a medical "home." This home establishes a centralized hub from which all health care can begin and can be coordinated, no matter how many other caregivers become involved. Occasionally, Members may encounter barriers to effective relationships with their Primary Medical Provider. These obstacles may be cultural and language difficulties, geographical access, or simply personal preferences. Members who want to change their Primary Medical Provider may do so at any time, for any reason. Members also have the right to change health care plans, following specific rules and timelines. If a Member requests disenrollment, Anthem will provide information and assistance in the disenrollment process. Anthem notifies Primary Medical Providers of Member transfers through monthly enrollment reports. Primary Medical Providers can find these reports online through our secure Anthem website, MyAnthem, located at www.anthem.com > OTHER ANTHEM WEBSITES: Providers > Providers | Spotlight: State Sponsored Plans or by calling our Anthem Provider Helpline. The effective date of a Primary Medical Provider transfer will be the same as the date of the Member request. We are committed to supporting Providers’ practices as well. Providers have the right to request that a Member be reassigned to another Primary Medical Provider under certain conditions and following specific guidelines. Member Transfers & Disenrollment Primary Medical Provider-Initiated Member Transfers Primary Medical Providers can request Member reassignment to a different Primary Medical Provider by completing and submitting the Provider Request for Member Deletion from PMP Assignment form located in the Forms Library on the Providers Resources page at: www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. The Provider is expected to coordinate service for up to 30 days after the date Anthem receives the change request form. Upon completing the Primary Medical Provider change, Anthem forwards the Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 12: Page 144 Chapter 12: Member Transfers & Disenrollment Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan form and any other information related to the case to the customer care representative. This representative informs the Member of the change within 5 working days. The change will be effective the day Anthem makes it effective. Member Transfers & Disenrollment Primary Medical Provider-Initiated Member Disenrollment A Primary Medical Provider may request disenrollment of a Member from his or her primary care assignment. The Primary Medical Provider may request Member disenrollment for the following reasons: • • • • The Member is abusive to the Primary Medical Provider, exhibiting disruptive, unruly, threatening or uncooperative behavior The Member is abusive to staff, exhibiting disruptive, unruly, threatening or uncooperative behavior The Member misuses or loans their membership card to another person The Member fails to follow prescribed treatment plans To request disenrollment, the Primary Medical Provider must do the following: Complete the Provider Request for Member Deletion from PMP Assignment form located in the Forms Library on the Providers Resources page at: www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Mail or fax (preferred) the form to Anthem at: 1-866-408-7087 Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 Continue to manage the Member’s care, as required, until we can reassign the Member to another Primary Medical Provider, or not more than 30 days from the day we receive the Provider Request for Member Deletion from PMP Assignment form, whichever comes first. Prior to disenrollment, Anthem will make every attempt to resolve issues and keep the Member in our health care plan. If these attempts fail, Anthem will either reassign the Member to another Primary Medical Provider or forward the disenrollment request form to the appropriate state agency requesting Member reassignment to another health care plan. Member Transfers & Disenrollment Primary Medical Provider-Initiated Member Disenrollment Process The disenrollment process for abusive behavior and failure to follow prescribed treatment plan is as follows: The Primary Medical Provider completes the Provider Request for Member Deletion from PMP Assignment, and then mails or faxes it to Anthem. Anthem scans and logs the form into the system for tracking purposes. Anthem reassigns the Member a new Primary Medical Provider for continuity of care. The effective date is no later than 30 days from the date on the Provider Request for Member Deletion form. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 12: Page 145 Chapter 12: Member Transfers & Disenrollment Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Anthem logs the new Primary Medical Provider assignment into its tracking system. Anthem sends an ID card and fulfillment material to the Member indicating the newly assigned Primary Medical Provider’s name, address and telephone number. Anthem documents any abusive behavior and notifies the Fraud and Abuse department if abusive behavior continues. Anthem sends a warning letter to the Member stating that if the behavior continues, Anthem will file a disenrollment request with Indiana's Family and Social Services Administration (FSSA). If approval is granted by FSSA, Anthem will proceed with the disenrollment process. Anthem may also request disenrollment for a Member who has moved out of the service area. When a Member moves out of our service area, that Member is responsible for notifying the state of their new permanent address. After that, Indiana's Family and Social Services Administration will disenroll the Member from Anthem. Member Transfers & Disenrollment State Agency-Initiated Member Disenrollment Contracted state agencies inform Anthem of membership changes by sending daily and monthly enrollment reports. These reports contain all active membership data and incremental changes to eligibility records. Anthem disenrolls Members who are not listed on the monthly full replacement file effective as of the designated disenrollment date for the following reasons: • Admission to a long-term care or intermediate care facility beyond the month of admission and the following month Change in eligibility status County changes Death Incarceration Loss of benefits Member has other non-government or government sponsored health coverage Permanent change of residence out of service area Voluntary disenrollments Member Transfers & Disenrollment Member-Initiated Primary Medical Provider Transfers Members have the right to change their Primary Medical Provider at any time. When a Member enrolls in any of our programs, they can choose a Primary Medical Provider or allow their Primary Medical Provider to be assigned. After that, if they want to make a change, Members are instructed to call our Customer Care Center to request an alternate Primary Medical Provider. Anthem accommodates Member requests for transfers whenever possible. Our staff will work with the Member to make the new selection, focusing on special needs. Our policy is to maintain Continued Access to Care and Continuity of Care during the transfer process. When a Member calls to request a Primary Medical Provider change: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 12: Page 146 Chapter 12: Member Transfers & Disenrollment Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The Customer Care Center (CCC) representative checks the availability of the Member’s choice. If the Member can be assigned to the selected Primary Medical Provider, the CCC representative will do so. If the Primary Medical Provider is not available, the CCC representative will assist the Member in finding an available Primary Medical Provider. If the Member advises the CCC that he or she is hospitalized, the Primary Medical Provider change will take effect upon discharge. Anthem notifies Primary Medical Providers of Member transfers through monthly enrollment reports. Primary Medical Providers can request these reports by calling our Customer Care Center. The effective date of a Primary Medical Provider transfer will be the same as the date of the Member request. We may assign a Member retroactively. To support Member transfers, Primary Medical Providers are encouraged to maintain open panels. The state requires that 80% of Anthem’s Primary Medical Providers have open panels, and your open panel will assist us in meeting this requirement. **Open Panel: The commitment by an Anthem Provider to accept new Anthem Members. Member Transfers & Disenrollment Member Transfers to Other Plans Members can choose a different Managed Care Organization (MCO) on an annual basis during the open enrollment period. As required by federal regulations, this open enrollment period lasts for 90 calendar days. After the open enrollment period ends, Members remain with their chosen MCO for the remaining 12-month period. However, Members retain the right to change their Managed Care Organization when they have “just cause,” which can be any of the following: • Lack of access to necessary services covered under the MCO’s contract Lack of access to Providers experienced in dealing with the Member’s health care needs MCO does not, for moral or religious objections, cover the services the Member seeks Member’s concerns over quality of care Member needs related services performed at the same time and not all related services are available within the MCO’s network Member's Primary Medical Provider leaves the MCO and participates with another MCO under contract with the state of Indiana, so long as the Member requests transfer to that MCO Member Transfers & Disenrollment Member Disenrollment from the Plan Member disenrollment may be requested by the Member, Anthem or the Indiana Family and Social Services Administration (FSSA). If the request comes from a Member and includes a Member grievance, the grievance will be processed separately through the grievance process. Disenrollment may result in the following: • Enrollment with another Plan Termination of eligibility Return to traditional Medicaid for continuity of care if the Member's benefits fall into a voluntary aid code Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 12: Page 147 Chapter 12: Member Transfers & Disenrollment Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Hoosier Healthwise and Healthy Indiana Plan Members can request disenrollment from our Plan at any time and without cause. The Member must notify the state's Medicaid enrollment broker of the decision to disenroll. If the enrollee is a mandatory Medicaid recipient, the enrollment broker instructs him or her to select another health plan option. If the enrollee does not make a choice, the enrollment broker automatically assigns another health plan to the enrollee. The enrollment broker offers voluntary Medicaid enrollees the option to join another plan, if one is available, or return to the fee-for-service coverage plan. When Members enroll in our program, we provide instructions on disenrollment procedures. Disenrollments become effective the last day of the calendar month following administrative cut-off or are subject to state cut-off. If a Member asks a Provider how to disenroll from Anthem, the Provider should direct the Member to call the Customer Care Center at: 1-866-408-6131. From there, the Member will be transferred to the state's enrollment broker phone number. The state's enrollment broker determines membership eligibility, enrollment and disenrollment. Please Note: Providers may not take retaliatory action against any Member for requesting transfer or disenrollment. Member Transfers & Disenrollment Member-Initiated Disenrollment Process When Anthem’s Customer Care Center (CCC) receives a call from a Member who wants to disenroll, the CCC follows these steps: 1. The CCC representative attempts to find out the reason for the request. 2. If the situation is something that the CCC representative can address and resolve, the representative reminds the Member that he or she has the right to request disenrollment, but also offers to resolve the issue. The representative then asks the Member if he or she wants to delay the disenrollment process pending resolution. 3. If a Member agrees to allow us to attempt resolution, Anthem’s CCC representative initiates the process that would properly address the situation. 4. If the Member declines, the CCC representative refers the Member to the Indiana's FSSA and provides the Member with the FSSA phone number. 5. The CCC representative informs the Member that the disenrollment process will take 15 to 45 days. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 12: Page 148 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 13: GRIEVANCES & APPEALS Hoosier Healthwise: Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan: Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Grievances & Appeals Overview We encourage Anthem Providers and Members to seek resolution of issues through our Grievances & Appeals process. Grievances are tracked and trended, resolved within established time frames and referred to peer review when needed. Anthem's Grievances & Appeals process meets all requirements of state law and accreditation agencies. The building blocks of this process are the Grievance and the Appeal. **Grievance: Any expression of dissatisfaction to Anthem by a Provider or Member about any matter other than an Action or Adverse Determination. **Appeal: A formal request for Anthem to review an Action or Adverse Determination. An Action or Adverse Determination is defined as follows: **Action/Adverse Determination: A denial, modification or reduction of services based on eligibility, benefit coverage or medical necessity. If a Provider or Member has a grievance, Anthem would like to hear from them, either by phone or in writing. Providers and Members have the right to file a grievance regarding any aspect of Anthem’s services. Please Note: Anthem does not discriminate against Members or Providers for filing a grievance or an appeal. Providers are prohibited from penalizing a Member in any way for filing a grievance. Provider Grievances & Appeals are classified into the following two categories: Provider Grievances relating to the operation of the Plan, including: o Benefit Interpretation o Claim Processing o Reimbursement Provider Appeals related to Actions/Adverse Determinations Member Grievances can include, but are not limited to, the following: Access to health care services Care and treatment by a Provider Issues having to do with how we conduct business Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 13: Page 149 Chapter 13: Grievances & Appeals Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Please Note: Anthem offers an Expedited Grievances & Appeals process for decisions involving urgently needed care. Both standard and expedited grievances and appeals are reviewed by a person who is not subordinate to the initial decision-maker. Grievances & Appeals Provider Grievances Relating to the Operation of the Plan A Provider may be dissatisfied or concerned about another Provider, a Member, or an operational issue, including claims processing and reimbursement, If the Provider wants to file a Grievance, please use the Provider Grievance Form located in the Forms Library on the Providers Resources page at: www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Provider grievances must be submitted in writing and include the following: Provider’s name Date of the incident Description of the incident The Grievance should be submitted to the following address: ATTN: Appeals and Grievances Department Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 Providers may also fax the grievance to: 1-866-387-2968. A Grievance may be filed up to 60 calendar days from the date the Provider became aware of the problem. Anthem may request medical records or an explanation of the issues raised in the Grievance in the following ways: By telephone By fax, with a signed and dated letter By mail, with a signed and dated letter The timelines for responding to the request for more information are as follows: Standard Grievances or Appeals: Providers must comply with the request for additional information within 10 days of the date that appears on the request. Expedited Grievances or Appeals: Providers must comply with the request for additional information within 24 hours of the date of our request. Providers are notified in writing of the resolution, including their right of appeal, if any. Findings or decisions of peer review or quality of care issues are not disclosed. When to Expect Resolution for a Grievance or Appeal Provider Grievances: Anthem sends a written resolution letter to the Provider within 30 calendar days of the receipt of the Grievance. Provider Appeals: Anthem sends a written resolution letter to the Provider within 30 calendar days of the receipt of the Appeal. Grievances and Appeals Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 13: Page 150 Chapter 13: Grievances & Appeals Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Claims Disputes If a Provider does not agree with the outcome of a claim determination, a Claims Dispute is the process by which the decision may be challenged. If there is a full or partial claim rejection or the payment is not the amount expected, submit the claims dispute Provider Dispute /Resolution Request form located in the Forms Library on the Providers Resources page at: www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. This form must be received by Anthem within 60 days from the date on the Explanation of Benefits. Multiple claims for the same situation may be submitted on one form. Mail to: ATTN: Appeals and Grievances Department Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 As an alternative, your Claims Dispute can be sent electronically at www.availity.com. Grievances and Appeals Claims Disputes Resolutions Claims Disputes are resolved within 30 days of receipt of the written request. When we resolve a Claim Dispute regarding a previous claim disposition, a resolution letter with the details of our decision is sent to the Provider. If a Provider is not satisfied with the outcome of the review process, there are additional steps that can be taken: Mediation (per the Anthem physician agreement) Arbitration (per the Anthem physician agreement) If the above processes have been exhausted, the Provider may file a complaint with: Indiana Family and Social Services Administration (FSSA) 402 W. Washington Street Room W374, MS07 Indianapolis, IN 46204-2739 FSSA Phone: 1-317-233-4454 Grievances & Appeals Member Grievances & Appeals To help ensure that Members' rights are protected, all Anthem Members are entitled to a grievance and appeals process. The building blocks of this process are the Grievance, the Grievance Appeal (a request to review a grievance decision), and the Appeal: **Grievance: Any expression of dissatisfaction by a Member to Anthem about any matter other than an Action or Adverse Determination. ** Grievance Appeal: A formal request for Anthem to review a grievance resolution. **Appeal: A formal request for Anthem to review an Action or Adverse Determination. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 13: Page 151 Chapter 13: Grievances & Appeals Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Grievances & Appeals Members: When to File Members have the following periods of time to file: Grievance: Within 60 days of the date the Member became aware of the issue Grievance Appeal: Within 30 days of the date when the grievance was resolved Appeal: Within 30 days of the date on the notification letter of denial Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 13: Page 152 Chapter 13: Grievances & Appeals Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Grievances & Appeals Members: Grievances If a Member wants to file a Grievance, he should fill out a Member Grievance Form or write a letter telling us about the problem. The Member Grievance Form is located in the Forms Library on the Providers Resources page at: www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Member grievance forms are also available at the places where Members receive their health care, such as their Primary Medical Provider’s office. When filing the grievance, the Member will need to tell us the following: Who is part of the grievance What happened When it happened Where it happened Why they were not happy with the health care services Attach documents that will help us look into the problem The Grievance Form should be mailed to: ATTN: Appeals and Grievances Department Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 Grievance Fax: 1-866-387-2968 If the Member cannot mail the form or letter, we will assist the Member by documenting a verbal request. Interpreter services, including sign language interpreters, are available to the Member throughout the grievance and appeals process, at no cost, by contacting the Customer Care Center. Grievances & Appeals Members: Grievance Appeals If a Member is not satisfied by the response to a grievance, the Member may file a Grievance Appeal. The Member Grievance Form, which Members may request by calling the Customer Care Center at 1-866-408-6131, may be filed by fax or mail to the following address: ATTN: Appeals and Grievances Department Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 Grievance Appeal FAX: 1-866-387-2968 After we receive the Member's Grievance Form by fax or mail, we will send an acknowledgment letter within 3 business days from the date we receive it. If we receive a request for an Expedited Grievance Appeal, the Medical Director will review the request without delay to determine if the request involves an imminent and/or serious threat to the health of the Member, including, but not limited to, severe Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 13: Page 153 Chapter 13: Grievances & Appeals Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan pain and potential loss of life, limb or major bodily function. This determination is made within one working day of the receipt of the expedited request. If the request meets the criteria for an Expedited Grievance Appeal, we immediately acknowledge it by telephone, if possible. Expedited Grievance Appeals are resolved within 48 hours of receipt. If the Medical Director determines a request involves medical care or treatment for which the application of the standard time period is appropriate the request will be handled and resolved in 45 calendar days. A Grievances & Appeals representative immediately notifies the Member by telephone, if possible, of the determination. In addition, a Grievances & Appeals associate provides the Member with a written notice of the denial to expedite the resolution within 2 calendar days of the receipt of the Grievance Appeal. Grievances & Appeals Members: Grievance Appeal Resolutions Anthem will investigate the Member’s Grievance Appeal to develop a resolution. This investigation includes the following steps: Anthem will have the grievance reviewed by appropriate staff and, if necessary, the Medical Director. Anthem may request medical records or an explanation from the Provider(s) involved in the case. Anthem will notify Providers of the need for additional information either by phone, mail or fax. Written correspondence to Providers will include a signed and dated letter. Providers are expected to comply with requests for additional information within 10 calendar days. Anthem will arrange a Grievance Appeal Panel meeting within 25 calendar days from the date of receiving the Grievance Appeal, where the Member can communicate their concerns directly to the panel members. The Member will receive a Grievance Appeal Resolution Letter within 45 calendar days of the date we receive the Grievance Appeal request. The letter will: Describe their Grievance Appeal Tell them what will be done to solve the problem Tell them how to ask for a Medicaid Hearing or an External Independent Review Tell them how to contact the Hoosier Healthwise or Indiana Family Social Services Administration Grievances & Appeals Members Appeals If the Member’s grievance is related to an Action or Adverse Determination, it is considered an Appeal. **Action/Adverse Determination: The denial or limited authorization of a requested service, including the type or level of service. Actions/Adverse Determinations may include the following: Denial or limited authorization of a requested service, including the type or level of service The reduction, suspension or termination of a previously authorized service Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 13: Page 154 Chapter 13: Grievances & Appeals Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The denial, in whole or in part, of payment for service Failure to provide services in a timely manner, as defined by the State Failure of Anthem to act within required timeframes For a resident of a rural area with only one Contractor, the denial of a Member’s request to exercise his right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside of the network (if applicable) If a Member would like to file an Appeal with regard to how we solved their problem, they must notify us within 30 calendar days of the date on the Notification Letter of Denial. The request for an Appeal must be filed in writing following an oral request, unless the Member files and expedited appeal. Please Note: Anthem will resolve any grievance or appeal, internal or external, at no cost to the Member. Member Appeals are divided into two categories: Standard Appeals and Expedited Appeals. **Standard Appeals: The appropriate process when a Member or his/her representative requests that Anthem reconsider the denial of a service or payment for services, in whole or in part. **Expedited Appeals: The appropriate process when the amount of time necessary to participate in a standard appeal process could jeopardize the Member’s life, health or the ability to maintain or regain maximum function. Members have the right to appeal Anthem’s denial of services or payment for services, in whole or in part. A denial of this type is called an Action or Adverse Determination. With the exception of expedited appeals, all oral appeals must be confirmed in writing and signed by the Member or his/her representative. Grievances & Appeals Member Appeals: Response to Standard Appeals Once an oral or written appeal request is received, the case is taken under consideration and investigated by the Grievances & Appeals department. The Member, his/her representative and the Provider are all given the opportunity to submit written comments and documentation relevant to the appeal. Anthem may request medical records or a Provider explanation of the issues raised in the appeal in the following ways: By telephone By fax, with a signed and dated letter By mail, with a signed and dated letter Providers are expected to comply with the request for additional information within 10 calendar days. When the appeal is the result of a medical necessity determination, a health care professional who was not involved in the initial decision reviews the case. The health care professional contacts the Provider, if needed, to discuss possible alternatives. Grievances & Appeals Member Appeals: Resolution of Standard Appeals Standard appeals are resolved within 20 business days of receipt of the initial written or oral request. Members are notified in writing of the appeal resolution and their right to further appeal (if any). Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 13: Page 155 Chapter 13: Grievances & Appeals Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Grievances & Appeals Member Appeals: Extensions The resolution time frame for an appeal not related to an ongoing hospitalization or emergency may be extended up to 10 business days if: The Member or his representative requests an extension Anthem shows that there is a need for additional information and that the delay is in the Member’s interest Grievances & Appeals Member Appeals: Expedited If the amount of time necessary to participate in a standard appeal process could jeopardize the Member’s life, health or ability to attain, maintain or regain maximum function, the Member may request an Expedited Appeal. Anthem will inform the Member of the time available for providing information and that limited time is available for expedited appeals. Members may request an expedited appeal by calling our Customer Care Center at: 866-408-6131. Grievances & Appeals Member Appeals: Timeline for an Expedited Appeal Members have the right to request an Expedited Appeal within 30 calendar days from the date on the initial Notice of Action letter. Expedited appeals are acknowledged by telephone, if possible, immediately. Anthem will follow up with an acknowledgement in writing. If Anthem denies a request for an expedited appeal, Anthem must: Transfer the appeal to the time frame for standard resolution. Make a reasonable effort to give the Member prompt oral notice of the denial, and follow up within 2 calendar days with a written notice. Grievances & Appeals Member Appeals: Response to Expedited Appeals Anthem may request medical records or a Provider explanation of the issues raised in an expedited appeal by the following means: By Phone By Fax, with a signed and dated letter By Mail, with a signed and dated letter Providers are expected to comply with the request for additional information within 24 hours. Grievances & Appeals Member Appeals: Resolution of Expedited Appeals Anthem resolves expedited appeals as quickly as possible and within 48 hours. The Member is notified by telephone of the resolution, if possible. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 13: Page 156 Chapter 13: Grievances & Appeals Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Grievances & Appeals Member Appeals: Other Options for Filing Grievances After exhausting Anthem’s Grievances & Appeals process, if a Member is still dissatisfied with the decision, the Member has the right to request an External Independent Review (EIR) or file an appeal with the Indiana FSSA to request a State Fair Hearing. Grievances & Appeals Member Appeals: External Independent Review The Member, the Member’s authorized representative, the Provider, or Provider on behalf of a Member may file a written request for an External Independent Review (EIR) through the Grievances & Appeals department within 45 calendar days after the Member is notified of Anthem’s resolution. The process is as follows: Anthem sends a letter acknowledging receipt of the request for the EIR within 3 business days for a standard request and within 24 hours for an expedited request. Anthem selects an EIR agency from the list of organizations certified by the state of Indiana. All documents related to the Member’s appeal case are forwarded to the review agency. If at any time during the EIR process the Member submits information that was not considered during the utilization review or appeal determination processes, Anthem will reconsider its resolution. At this time the EIR agency will stop their review. Anthem will make a decision in this reconsideration process within 72 hours of receipt of the information for an expedited request and within 15 business days of the receipt of this information for a standard request. If the decision is adverse to the Member, the Member may request that the EIR agency resume their review. The EIR agency must make a decision on an expedited request within 72 hours after the request is filed. For a standard request the agency must make a decision within 15 business days after the request is filed. The EIR agency notifies Anthem and the Member of their decision. Their decision is binding on Anthem. Grievances & Appeals Member Appeals: State Fair Hearing Anthem Members may request a State Fair Hearing after they have exhausted all of Anthem’s internal appeal processes. The request must be filed within 30 calendar days of the initial action to be reviewed. The request must be submitted in writing to the State of Indiana: Indiana Family Social Services Administration Hearings and Appeals Section, MS-04 402 W. Washington Street, Room W392 Indianapolis, IN 46204-2773 Once the state receives the Member’s request, the process is as follows: The state sends a notice of the hearing request to Anthem. Upon receipt of the request, all documents related to the request and are forwarded to the state. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 13: Page 157 Chapter 13: Grievances & Appeals Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The state notifies all parties of the date, time and place of the hearing. Representatives from our administrative, medical and legal departments may attend the hearing to present testimony and arguments. Our representatives may cross-examine the witnesses and offer rebutting evidence. An Administrative Law Judge renders a decision in the hearing within 90 business days of the date the hearing request was made. If the judge overturns Anthem’s position, we must adhere to the judge’s decision and ensure that it is carried out. Confidentiality All Grievances and Appeals are handled in a confidential manner and we do not discriminate against a Member for filing a grievance or requesting a State Fair Hearing. We also notify Members of the opportunity to receive information about our Grievances & Appeals process; they can request a translated version in a language other than English. Discrimination Members who contact us with an allegation of discrimination are immediately informed of the right to file a Grievance. This also occurs when one of our representatives working with a Member identifies a potential act of discrimination. The Member is advised to submit an oral or written account of the incident and is assisted in doing so, if he requests assistance. We document, and track and trend all alleged acts of discrimination. A Grievances & Appeals associate will review and trend cultural and linguistic grievances in collaboration with a cultural and linguistic specialist. Continuation of Benefits for Indiana Medicaid Members during Appeal Hoosier Healthwise and Healthy Indiana Plan Members may continue benefits while their Appeal is pending in accordance with federal regulations when all of the following criteria are met: Member or representative must request the Appeal within 10 days of our mail date of the adverse action notification, or prior to the effective date on the written notice if the initial notification was made by phone. The Appeal involves the termination, suspension, or reduction of a previously authorized course of treatment Services were ordered by an authorized Provider The original period covered by the initial authorization has not expired Member requests extension of benefits Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 13: Page 158 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 14: CREDENTIALING & RE-CREDENTIALING Hoosier Healthwise: Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan: Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Credentialing and Re-credentialing Credentialing Program Structure The National Credentials Committee (NCC) is the authorized entity for the development and maintenance of National Credentialing Policy. Policies approved by NCC will govern credentialing of network practitioners and Health Delivery Organizations (HDOs), including but not limited to scope, criteria, confidentiality, delegation and appeals. Policies established by the National Credentials Committee will be presented to Anthem’s Credentials Committee for input, review and adoption. The NCC establishes a local credentialing and peer review body known as the Credentials Committee. The Credentials Committee (CC) is authorized by the NCC to evaluate and determine eligibility for practitioners and HDOs to participate in the credentialed networks and be listed in the Provider directories. Credentialing and Re-credentialing Credentialing Program Scope Anthem credentials the following health care practitioners: medical doctors, doctors of osteopathic medicine, doctors of podiatry, chiropractors, and optometrists providing services covered under the Anthem’s Health Benefits Plan and doctors of dentistry providing Health Services covered under the Anthem’s Health Benefits Plan including oral maxillofacial surgeons. Anthem also credentials behavioral health practitioners, including psychiatrists and physicians who are certified or trained in addiction psychiatry, child and adolescent psychiatry, and geriatric psychiatry; doctoral and clinical psychologists who are state licensed; master’s level clinical social workers who are state licensed; master’s level clinical nurse specialists or psychiatric nurse practitioners who are nationally and state certified and state licensed; and other behavioral health care specialists who are licensed, certified, or registered by the state to practice independently. In addition, Medical Therapists (e.g., physical therapists, speech therapists and occupational therapists) and other individual health care practitioners listed in Anthem’s Network directory will be credentialed. Anthem credentials the following HDOs: hospitals; home health agencies; skilled nursing facilities; (nursing homes); free-standing surgical centers; lithotripsy centers treating kidney stones and freestanding cardiac catheterization labs if applicable to certain regions; as well as behavioral health facilities providing mental health and/or substance abuse treatment in an inpatient, residential or ambulatory setting. Additional facilities and ancillary providers, including long term care services and support providers, are also subject to credentialing and re-credentialing. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2013 Chapter 14: Page 159 Chapter 14: Credentialing & Re-Credentialing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Credentialing and Re-credentialing Credentials Committee The decision to accept, retain, deny or terminate a practitioner’s participation in a Network or Plan Program is conducted by a peer review body, known as Anthem’s Credentials Committee (CC). The CC will meet at least once every 45 days. The presence of a majority of voting CC members constitutes a quorum. The chief medical officer, or a designee appointed in consultation with the vice president of Medical and Credentialing Policy, will chair the CC and serve as a voting member (the Chair of the CC). The CC will include at least two participating practitioners, including one who practices in the specialty type that most frequently provides services to Anthem Covered Individuals and who falls within the scope of the credentialing program, having no other role in Anthem’s Network Management. The Chair of the CC may appoint additional Network practitioners of such specialty type as deemed appropriate for the efficient functioning of the CC. The CC will access various specialists for consultation as needed to complete the review of a practitioner’s credentials. A committee member will disclose and abstain from voting on a practitioner if the committee member (i) believes there is a conflict of interest, such as direct economic competition with the practitioner; or (ii) feels his or her judgment might otherwise be compromised. A committee member will also disclose if he or she has been professionally involved with the practitioner. Determinations to deny an applicant’s participation, or terminate a practitioner from participation in one or more Networks or Plan Programs, require a majority vote of the voting members of the CC in attendance, the majority of whom are Network Providers. During the credentialing process, all information that is obtained is highly confidential. All CC meeting minutes and practitioner files are stored in locked cabinets and can only be seen by appropriate Credentialing staff, medical directors and CC members. Documents in these files may not be reproduced or distributed, except for confidential peer review and credentialing purposes. Practitioners and HDOs are notified that they have the right to review information submitted to support their credentialing applications. In the event that credentialing information cannot be verified, or if there is a discrepancy in the credentialing information obtained, the Credentialing staff will contact the practitioner or HDO within 30 calendar days of the identification of the issue. This communication will specifically notify the practitioner or HDO of the right to correct erroneous information or provide additional details regarding the issue in question. This notification will also include the specific process for submission of this additional information, including where it should be sent. Depending on the nature of the issue in question, this communication may occur verbally or in writing. If the communication is verbal, written confirmation will be sent at a later date. All communication on the issue(s) in question, including copies of the correspondence or a detailed record of phone calls, will be clearly documented in the practitioner’s credentials file. The practitioner or HDO will be given no less than 14 calendar days in which to provide additional information. Anthem may request and will accept additional information from the applicant to correct or explain incomplete, inaccurate, or conflicting credentialing information. The CC will review the information and rationale presented by the applicant to determine if a material omission has occurred or if other credentialing criteria are met. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 160 Chapter 14: Credentialing & Re-Credentialing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Credentialing and Re-credentialing Nondiscrimination Policy Anthem will not discriminate against any applicant for participation in its Plan Programs or Networks on the basis of race, gender, color, creed, religion, national origin, ancestry, sexual orientation, age, veteran, or marital status or any unlawful basis not specifically mentioned herein. Additionally, Anthem will not discriminate against any applicant on the basis of the risk of population they serve or against those who specialize in the treatment of costly conditions. Other than gender and language capabilities that are provided to the Covered Individuals to meet their needs and preferences, this information is not required in the credentialing and re-credentialing process. Determinations as to which practitioners/HDOs require additional individual review by the CC are made according to predetermined criteria related to professional conduct and competence as outlined in Anthem Credentialing Program Standards. CC decisions are based on issues of professional conduct and competence as reported and verified through the credentialing process. Credentialing and Re-credentialing Initial Credentialing Each practitioner or HDO must complete a standard application form when applying for initial participation in the Anthem Network. This application may be a state mandated form or a standard form created by or deemed acceptable by Anthem. For practitioners, the Council for Affordable Quality Healthcare (CAQH), a Universal Credentialing Datasource is utilized. CAQH is building the first national Provider credentialing database system, which is designed to eliminate the duplicate collection and updating of provider information for health plans, hospitals and practitioners. To learn more about CAQH, visit their website at www.CAQH.org. Anthem will verify those elements related to an applicants’ legal authority to practice, relevant training, experience and competency from the primary source, where applicable, during the credentialing process. All verifications must be current and verified within the 180 calendar-day period prior to the CC making its credentialing recommendation or as otherwise required by applicable accreditation standards. During the credentialing process, Anthem will review verification of the credentialing data as described in the following tables unless otherwise required by regulatory or accrediting bodies. These tables represent minimum requirements. A. Practitioners Verification Element License to practice in the state(s) in which the practitioner will treat Covered Individuals. Hospital admitting privileges at a TJC, NIAHO or AOA accredited hospital, or a Network hospital previously approved by the committee. DEA, CDS and state controlled substance certificates The DEA/CDS must be valid in the state(s) in which practitioner will treat Covered Individuals. Practitioners who see members in more than one state must have a DEA/CDS for each state. Malpractice insurance Malpractice claims history Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 161 Chapter 14: Credentialing & Re-Credentialing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Verification Element Board certification or highest level of medical training or education Work history State or Federal license sanctions or limitations Medicare, Medicaid or FEHBP sanctions National Practitioner Data Bank report B. Health Delivery Organizations (HDOs) Verification Element Accreditation, if applicable License to practice, if applicable Malpractice insurance Medicare certification, if applicable Department of Health Survey Results or recognized accrediting organization certification License sanctions or limitations, if applicable Medicare, Medicaid or FEHBP sanctions Credentialing and Re-credentialing Re-credentialing The re-credentialing process incorporates re-verification and the identification of changes in the practitioner’s or HDO’s licensure, sanctions, certification, health status and/or performance information (including, but not limited to, malpractice experience, hospital privilege or other actions) that may reflect on the practitioner’s or HDO’s professional conduct and competence. This information is reviewed in order to assess whether practitioners and HDOs continue to meet Anthem’s credentialing standards. During the re-credentialing process, Anthem will review verification of the credentialing data as described in the tables under Initial Credentialing unless otherwise required by regulatory or accrediting bodies. These tables represent minimum requirements. All applicable practitioners and HDOs in the Network within the scope of Anthem’s Credentialing Program are required to be re-credentialed every three years unless otherwise required by contract or state regulations. Credentialing and Re-credentialing Health Delivery Organizations New HDO applicants will submit a standardized application to Anthem for review. If the candidate meets Anthem’s screening criteria, the credentialing process will commence. To assess whether participating Anthem Network HDOs, within the scope of the Credentialing Program, meet appropriate standards of professional conduct and competence, they are subject to credentialing and recredentialing programs. In addition to the licensure and other eligibility criteria for HDOs, as described in detail in Anthem’s Credentialing Program Standards, all Network HDOs are required to maintain accreditation by an appropriate, recognized accrediting body or, in the absence of such accreditation, Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 162 Chapter 14: Credentialing & Re-Credentialing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Anthem may evaluate the most recent site survey by Medicare or the appropriate state oversight agency for that HDO. Re-credentialing of HDOs occurs every three years unless otherwise required by regulatory or accrediting bodies. Each HDO applying for continuing participation in the Anthem Network must submit all required supporting documentation. On request, HDOs will be provided with the status of their credentialing application. Anthem may request, and will accept, additional information from the HDO to correct incomplete, inaccurate, or conflicting credentialing information. The CC will review this information and the rationale behind it, as presented by the HDO, and determine if a material omission has occurred or if other credentialing criteria are met. Credentialing and Re-credentialing Ongoing Sanction Monitoring To support certain credentialing standards between the re-credentialing cycles, Anthem has established an ongoing monitoring program. Credentialing performs ongoing monitoring to help ensure continued compliance with credentialing standards and to assess for occurrences that may reflect issues of substandard professional conduct and competence. To achieve this, the credentialing department will review periodic listings/reports within 30 calendar days of the time they are made available from the various sources including, but not limited to, the following: 1. 2. 3. 4. 5. 6. Office of the Inspector General (OIG) Federal Medicare/Medicaid Reports Office of Personnel Management (OPM) State licensing Boards/Agencies Covered Individual/Customer Services Departments Clinical Quality Management Dept. (including data regarding complaints of both a clinical and non-clinical nature, reports of adverse clinical events and outcomes, and satisfaction data, as available) 7. Other internal Anthem Departments 8. Any other verified information received from appropriate sources When a practitioner or HDO within the scope of credentialing has been identified by these sources, criteria will be used to assess the appropriate response including but not limited to: review by the Chair of Anthem’s CC, review by the Anthem’s Medical Director, referral to the CC or termination. Anthem’s credentialing departments will report Providers to the appropriate authorities as required by law. Credentialing and Re-credentialing Appeals Process Anthem has established policies for monitoring and re-credentialing practitioners and HDOs who seek continued participation in the Anthem Network or Plan Program. Information reviewed during this activity may indicate that the professional conduct and competence standards are no longer being met and Anthem may wish to terminate practitioners or HDOs. Anthem also seeks to treat practitioners and HDOs and applying Providers fairly, and thus provides practitioners and HDOs with a process to appeal determinations terminating participation in the Anthem Network or Plan Program for professional competence and conduct reasons, or which would otherwise result in a report to the National Practitioner Data Bank (NPDB). Additionally, Anthem will permit practitioners and HDOs who have been Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 163 Chapter 14: Credentialing & Re-Credentialing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan refused initial participation the opportunity to correct any errors or omissions which may have led to such denial (informal/reconsideration only). It is the intent of Anthem to give practitioners and HDOs the opportunity to contest a termination of the practitioner’s or HDO’s participation in the Anthem Network or Plan Program and those denials of request for initial participation which are reported to the NPDB that were based on professional competence and conduct considerations. Immediate terminations may be imposed due to the practitioner’s or HDO’s suspension or loss of licensure, criminal conviction, or Anthem’s determination that the practitioner’s or HDO’s continued participation poses an imminent risk of harm to Covered Individuals. A practitioner/HDO whose license has been suspended or revoked has no right to informal review/reconsideration or formal appeal. Credentialing and Re-credentialing Reporting Requirements When Anthem takes a professional review action with respect to a practitioner’s or HDO’s participation in the Anthem Network, Anthem may have an obligation to report such to the NPDB and/or Healthcare Integrity and Protection Data Bank (HIPDB). Once Anthem receives a verification of the NPDB report, the verification report will be sent to the state licensing board. The credentialing staff will comply with all state and federal regulations in regard to the reporting of adverse determinations relating to professional conduct and competence. These reports will be made to the appropriate, legally designated agencies. In the event that the procedures set forth for reporting reportable adverse actions conflict with the process set forth in the current NPDB Guidebook and the HIPDB Guidebook, the process set forth in the NPDB Guidebook and the HIPDB Guidebook will govern. Credentialing and Re-credentialing Eligibility Criteria – Health Care Practitioners Initial applicants must meet the following criteria in order to be considered for participation: A. Possess a current, valid, unencumbered, unrestricted and non-probationary license in the state(s) where he/she provides services to Covered Individuals B. Possess a current, valid, and unrestricted Drug Enforcement Agency (“DEA”) and/or Controlled Dangerous Substances (“CDS”) registration for prescribing controlled substances, if applicable to his/her specialty in which he/she will treat Covered Individuals; the DEA/CDS must be valid in the state(s) in which the practitioner will be treating Covered Individuals. Practitioners who see Covered Individuals in more than one state must have a DEA/CDS for each state C. Must not be currently debarred or excluded from participation in any of the following programs: Medicare, Medicaid or FEHBP D. For MDs, DOs, DPMs and oral and maxillofacial surgeons, the applicant must have current, in force board certification (as defined by the American Board of Medical Specialties (ABMS), American Osteopathic Association (AOA), Royal College of Physicians and Surgeons of Canada (RCPSC), College of Family Physicians of Canada (CFPC), American Board of Podiatric Surgery (ABPS), American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM) or American Board of Oral and Maxillofacial Surgery (ABOMS) in the clinical discipline for which they are applying. Individuals will be granted five years after completion of their residency program to meet this requirement 1. As alternatives, MDs and DOs meeting any one of the following criteria will be viewed as meeting the education, training and certification requirement: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 164 Chapter 14: Credentialing & Re-Credentialing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan a. Previous board certification (as defined by one of the following: ABMS, AOA, RCPSC or CFPC) in the clinical specialty or subspecialty for which they are applying which has now expired AND a minimum of 10 consecutive years of clinical practice. OR b. Training which met the requirements in place at the time it was completed in a specialty field prior to the availability of board certifications in that clinical specialty or subspecialty. OR c. Specialized practice expertise as evidenced by publication in nationally accepted peer review literature and/or recognized as a leader in the science of their specialty AND a faculty appointment of Assistant Professor or higher at an academic medical center and teaching Facility in Anthem Network AND the applicant’s professional activities are spent at that institution at least 50 percent of the time. 2. Practitioners meeting one of these three alternative criteria (a, b, c) will be viewed as meeting all Anthem education, training and certification criteria and will not be required to undergo additional review or individual presentation to the CC. These alternatives are subject to Anthem review and approval. Reports submitted by delegate to Anthem must contain sufficient documentation to support the above alternatives, as determined by Anthem. E. For MDs and DOs, the applicant must have unrestricted hospital privileges at a The Joint Commission (TJC), National Integrated Accreditation for Healthcare Organizations (NIAHO) or an AOA accredited hospital, or a Network hospital previously approved by the committee. Some clinical disciplines may function exclusively in the outpatient setting, and the CC may at its discretion deem hospital privileges not relevant to these specialties. Also, the organization of an increasing number of physician practice settings in selected fields is such that individual physicians may practice solely in either an outpatient or an inpatient setting. The CC will evaluate applications from practitioners in such practices without regard to hospital privileges. The expectation of these physicians would be that there is an appropriate referral arrangement with a Network/Participating Provider to provide inpatient care. Credentialing and Re-credentialing Criteria for Selecting Practitioners – New Applicants (Credentialing) 1. Submission of a complete application and required attachments that must not contain intentional misrepresentations; 2. Application attestation signed date within 180 calendar days of the date of submission to the CC for a vote; 3. Primary source verifications within acceptable timeframes of the date of submission to the CC for a vote, as deemed by appropriate accrediting agencies; 4. No evidence of potential material omission(s) on application; 5. Current, valid, unrestricted license to practice in each state in which the practitioner would provide care to Covered Individuals; 6. No current license action; 7. No history of licensing board action in any state; 8. No current federal sanction and no history of federal sanctions (per OIG and OPM report nor on NPDB report); 9. Possess a current, valid, and unrestricted DEA/CDS registration for prescribing controlled substances, if applicable to his/her specialty in which he/she will treat Covered Individuals. The DEA/CDS must be valid in the state(s) in which the practitioner will treat Covered Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 165 Chapter 14: Credentialing & Re-Credentialing 10. 11. 12. 13. 14. 15. 16. 17. 18. Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Individuals. Practitioners who treat Covered Individuals in more than one state must have a valid DEA/CDS for each applicable state. Initial applicants who have NO DEA/CDS certificate will be viewed as not meeting criteria and the credentialing process will not proceed. However, if the applicant can provide evidence that he has applied for a DEA the credentialing process may proceed if all of the following are met: a. It can be verified that this application is pending. b. The applicant has made an arrangement for an alternative practitioner to prescribe controlled substances until the additional DEA certificate is obtained. c. The applicant agrees to notify Anthem upon receipt of the required DEA. d. Anthem will verify the appropriate DEA/CDS via standard sources. i. The applicant agrees that failure to provide the appropriate DEA within a 90 day timeframe will result in termination from the Network. ii. Initial applicants who possess a DEA certificate in a state other than the state in which they will be treating Covered Individuals will be notified of the need to obtain the additional DEA. If the applicant has applied for additional DEA the credentialing process may proceed if ALL the following criteria are met: It can be verified that this application is pending and, The applicant has made an arrangement for an alternative practitioner to prescribe controlled substances until the additional DEA certificate is obtained, The applicant agrees to notify Anthem upon receipt of the required DEA, Anthem will verify the appropriate DEA/CDS via standard sources; applicant agrees that failure to provide the appropriate DEA within a 90 calendar day timeframe will result in termination from the Network, AND Must not be currently debarred or excluded from participation in any of the following programs: Medicare, Medicaid or FEHBP. No current hospital membership or privilege restrictions and no history of hospital membership or privileges restrictions; No history of or current use of illegal drugs or history of or current alcoholism; No impairment or other condition which would negatively impact the ability to perform the essential functions in their professional field. No gap in work history greater than six months in the past five years with the exception of those gaps related to parental leave or immigration where 12-month gaps will be acceptable. Other gaps in work history of six to 24 months will be reviewed by the Chair of the CC and may be presented to the CC if the gap raises concerns of future substandard professional conduct and competence. In the absence of this concern the Chair of the CC may approve work history gaps of up to two years. No history of criminal/felony convictions or a plea of no contest; A minimum of the past 10 years of malpractice case history is reviewed. Meets Credentialing Standards for education/training for specialty(ies) in which practitioner wants to be listed in an Anthem Network directory as designated on the application. This includes board certification requirements or alternative criteria for MDs and DOs and board certification criteria for DPMs and oral/maxillofacial surgeons; No involuntary terminations from an HMO or PPO; No "yes" answers to attestation/disclosure questions on the application form with the exception of the following: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 166 Chapter 14: Credentialing & Re-Credentialing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan a. Investment or business interest in ancillary services, equipment or supplies; b. Voluntary resignation from a hospital or organization related to practice relocation or facility utilization; c. Voluntary surrender of state license related to relocation or nonuse of said license; d. An NPDB report of a malpractice settlement or any report of a malpractice settlement that does not meet the threshold criteria. e. Non-renewal of malpractice coverage or change in malpractice carrier related to changes in the carrier’s business practices (no longer offering coverage in a state or no longer in business); f. Previous failure of a certification exam by a practitioner who is currently board certified or who remains in the five-year post residency training window. g. Actions taken by a hospital against a practitioner’s privileges related solely to the failure to complete medical records in a timely fashion; h. History of a licensing board, hospital or other professional entity investigation that was closed without any action or sanction. Note: the CC will individually review any practitioner who does not meet one or more of the criteria required for initial applicants. Practitioners who meet all participation criteria for initial or continued participation and whose credentials have been satisfactorily verified by the Credentialing department may be approved by the Chair of the CC after review of the applicable credentialing or re-credentialing information. This information may be in summary form and must include, at a minimum, practitioner’s name and specialty. Credentialing and Re-credentialing Currently Participating Applicants (Re-credentialing) 1. Submission of complete re-credentialing application and required attachments that must not contain intentional misrepresentations; 2. Re-credentialing application signed date within 180 calendar days of the date of submission to the CC for a vote; 3. Primary source verifications within acceptable timeframes of the date of submission to the CC for a vote, as deemed by appropriate accrediting agencies; 4. No evidence of potential material omission(s) on re-credentialing application; 5. Current, valid, unrestricted license to practice in each state in which the practitioner provides care to Covered Individuals; 6. * No current license probation; 7. * License is unencumbered; 8. No new history of licensing board reprimand since prior credentialing review; 9. * No current federal sanction and no new (since prior credentialing review) history of federal sanctions (per OIG and OPM Reports or on NPDB report); 10. Current DEA, CDS Certificate and/or state controlled substance certification without new (since prior credentialing review) history of or current restrictions; 11. No current hospital membership or privilege restrictions and no new (since prior credentialing review) history of hospital membership or privilege restrictions; OR for practitioners in a specialty defined as requiring hospital privileges who practice solely in the outpatient setting there exists a defined referral relationship with a Network/Participating Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 167 Chapter 14: Credentialing & Re-Credentialing 12. 13. 14. 15. 16. 17. 18. 19. Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Provider of similar specialty at a Network hospital who provides inpatient care to Covered Individuals needing hospitalization; No new (since previous credentialing review) history of or current use of illegal drugs or alcoholism; No impairment or other condition which would negatively impact the ability to perform the essential functions in their professional field; No new (since previous credentialing review) history of criminal/felony convictions, including a plea of no contest; Malpractice case history reviewed since the last CC review. If no new cases are identified since last review, malpractice history will be reviewed as meeting criteria. If new malpractice history is present, then a minimum of last five years of malpractice history is evaluated and criteria consistent with initial credentialing is used. No new (since previous credentialing review) involuntary terminations from an HMO or PPO; No new (since previous credentialing review) "yes" answers on attestation/disclosure questions with exceptions of the following: a. investment or business interest in ancillary services, equipment or supplies; b. voluntary resignation from a hospital or organization related to practice relocation or facility utilization; c. voluntary surrender of state license related to relocation or nonuse of said license; d. an NPDB report of a malpractice settlement or any report of a malpractice settlement that does not meet the threshold criteria; e. nonrenewal of malpractice coverage or change in malpractice carrier related to changes in the carrier’s business practices (no longer offering coverage in a state or no longer in business); f. previous failure of a certification exam by a practitioner who is currently board certified or who remains in the five-year post residency training window; g. actions taken by a hospital against a practitioner’s privileges related solely to the failure to complete medical records in a timely fashion; h. history of a licensing board, hospital or other professional entity investigation that was closed without any action or sanction. No QI data or other performance data including complaints above the set threshold. Re-credentialed at least every three years to assess the practitioner’s continued compliance with Anthem standards. *It is expected that these findings will be discovered for currently credentialed Providers and Facilities through ongoing sanction monitoring. Providers and Facilities with such findings will be individually reviewed and considered by the CC at the time the findings are identified. Note: the CC will individually review any credentialed Provider or Facility that does not meet one or more of the criteria for re-credentialing. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 168 Chapter 14: Credentialing & Re-Credentialing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Credentialing and Re-credentialing Additional Participation Criteria and Exceptions for Behavioral Health Practitioners (Non-Physician) Credentialing 1. Licensed Clinical Social Workers (LCSW) or other master level social work license type: a. Master or doctoral degree in social work with emphasis in clinical social work from a program accredited by the Council on Social Work Education (CSWE) or the Canadian Association on Social Work Education (CASWE). b. Program must have been accredited within three years of the time the practitioner graduated. c. Full accreditation is required, candidacy programs will not be considered. d. If master’s level degree does not meet criteria and practitioner obtained PhD training as a clinical psychologist, but is not licensed as such, the practitioner can be reviewed. To meet the criteria, the doctoral program must be accredited by the APA or be regionally accredited by the Council for Higher Education (CHEA). In addition, a doctor of social work from an institution with at least regional accreditation from the CHEA will be viewed as acceptable. 2. Licensed professional counselor (LPC) and marriage and family therapist (MFT) or other master level license type: a. Master’s or doctoral degree in counseling, marital and family therapy, psychology, counseling psychology, counseling with an emphasis in marriage, family and child counseling or an allied mental field. Master or doctoral degrees in education are acceptable with one of the fields of study above. b. Master or doctoral degrees in divinity do not meet criteria as a related field of study. c. Graduate school must be accredited by one of the Regional Institutional Accrediting Bodies and may be verified from the Accredited Institutions of Post- Secondary Education, APA, Council for Accreditation of Counseling and Related Educational Programs (CACREP), or Commission on Accreditation for Marriage and Family Therapy Education (“COAMFTE”) listings. The institution must have been accredited within three years of the time the practitioner graduated. d. If master’s level degree does not meet criteria and practitioner obtained PhD training as a clinical psychologist, but is not licensed as such, the practitioner can be reviewed. To meet criteria this doctoral program must either be accredited by the APA or be regionally accredited by the CHEA. In addition, a doctoral degree in one of the fields of study noted above from an institution with at least regional accreditation from the CHEA will be viewed as acceptable. 3. Clinical nurse specialist/psychiatric and mental health nurse practitioner: a. Master’s degree in nursing with specialization in adult or child/adolescent psychiatric and mental health nursing. Graduate school must be accredited from an institution accredited by one of the Regional Institutional Accrediting Bodies within three years of the time of the practitioner’s graduation. b. Registered Nurse license and any additional licensure as an Advanced Practice Nurse/Certified Nurse Specialist/Adult Psychiatric Nursing or other license or certification as dictated by the appropriate State(s) Board of Registered Nursing, if applicable. c. Certification by the American Nurses Association (ANA) in psychiatric nursing. This may be any of the following types: Clinical Nurse Specialist in Child or Adult Psychiatric Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 169 Chapter 14: Credentialing & Re-Credentialing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Nursing, Psychiatric and Mental Health Nurse Practitioner or Family Psychiatric and Mental Health Nurse Practitioner. d. Valid, current, unrestricted DEA Certificate, where applicable with appropriate supervision/consultation by a Provider as applicable by the state licensing board. For those who possess a DEA Certificate, the appropriate CDS Certificate if required. The DEA/CDS must be valid in the state(s) in which the practitioner will treat Covered Individuals. 4. Clinical Psychologists: a. Valid state clinical psychologist license. b. Doctoral degree in clinical or counseling, psychology or other applicable field of study from an institution accredited by the APA within three years of the time of the practitioner’s graduation. c. Education/Training considered as eligible for an exception is a practitioner whose doctoral degree is not from an APA accredited institution but who is listed in the National Register of Health Service Providers in Psychology or is a Diplomat of the American Board of Professional Psychology. d. Master’s level therapists in good standing in the Network, who upgrade their license to clinical psychologist as a result of further training, will be allowed to continue in the Network and will not be subject to the above education criteria. 5. Clinical Neuropsychologist: a. Must meet all the criteria for a clinical psychologist listed in C.4 above and be Board certified by either the American Board of Professional Neuropsychology (ABPN) or American Board of Clinical Neuropsychology (ABCN). b. A practitioner credentialed by the National Register of Health Service Providers in Psychology with an area of expertise in neuropsychology may be considered. c. Clinical neuropsychologists who are not board certified or listed in the National Register will require CC review. These practitioners must have appropriate training and/or experience in neuropsychology as evidenced by one or more of the following: i. Transcript of applicable pre-doctoral training OR ii. Documentation of applicable formal one year post-doctoral training (participation in CEU training alone would not be considered adequate) OR iii. Letters from supervisors in clinical neuropsychology (including number of hours per week) OR iv. Minimum of five years’ experience practicing neuropsychology at least 10 hours per week Credentialing and Re-credentialing Eligibility Criteria – Health Delivery Organizations (HDOs) All HDOs must be accredited by an appropriate, recognized accrediting body. In the absence of such accreditation, Anthem may evaluate the most recent site survey by Medicare or the appropriate state oversight agency. Non-accredited HDOs are subject to individual review by the CC and will be considered for Covered Individual access need only when the CC review indicates compliance with Anthem’s standards and there are no deficiencies noted on the Medicare or state oversight review which would adversely affect quality or care or patient safety. HDOs are re-credentialed at least every three years to assess the HDO’s continued compliance with Anthem’s standards. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 170 Chapter 14: Credentialing & Re-Credentialing Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan General Criteria for HDOs: 1. Valid, current and unrestricted license to operate in the state(s) in which it will provide services to Covered Individuals. The license must be in good standing with no sanctions. 2. Valid and current Medicare certification. 3. Must not be currently debarred or excluded from participation in any of the following programs: Medicare, Medicaid or FEHBP. 4. Liability insurance acceptable to Anthem. 5. If not appropriately accredited, HDO must submit a copy of its CMS or state site survey for review by the CC to determine if Anthem’s quality and certification criteria standards have been met. Additional Participation Criteria for HDO by Provider Type MEDICAL FACILITIES Facility Type (MEDICAL CARE) Acute Care Hospital Ambulatory Surgical Centers Free Standing Cardiac Catheterization Facilities Lithotripsy Centers (Kidney stones) Home Health Care Agencies Skilled Nursing Facilities Nursing Homes BEHAVIORAL HEALTH Facility Type (BEHAVIORAL HEALTH CARE) Acute Care Hospital—Psychiatric Disorders Residential Care—Psychiatric Disorders Partial Hospitalization/Day Treatment— Psychiatric Disorders Intensive Structured Outpatient Program— Psychiatric Disorders Acceptable Accrediting Agencies TJC,HFAP, NIAHO TJC,HFAP, AAPSF, AAAHC, AAAASF, IMQ TJC, HFAP (may be covered under parent institution) TJC TJC, CHAP, ACHC TJC, CARF TJC TJC, HFAP NIAHO, TJC, HFAP, NIAHO CARF TJC, HFAP, NIAHO CARF for programs associated with an acute care facility or Residential Treatment Facilities. TJC, HFAP NIAHO for programs affiliated with an acute care hospital or health care organization that provides psychiatric services to adults or adolescents CARF if program is a residential treatment center providing psychiatric services Acute Inpatient Hospital—Chemical Dependency/Detoxification and Rehabilitation Acute Inpatient Hospital—Detoxification Only Facilities Residential Care—Chemical Dependency Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan TJC, HFAP, NIAHO TJC, HFAP, NIAHO TJC, HFAP, NIAHO, CARF Version 2.2 June 1, 2014 Chapter 14: Page 171 Chapter 14: Credentialing & Re-Credentialing Partial Hospitalization/Day Treatment— Chemical Dependency Intensive Structured Outpatient Program— Chemical Dependency Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan TJC, NIAHO for programs affiliated with a hospital or health care organization that provides drug abuse and/or alcoholism treatment services to adults or adolescents; CHAMPUS or CARF for programs affiliated with a residential treatment center that provides drug abuse and/or alcoholism treatment services to adults or adolescents TJC, NIAHO for programs affiliated with a hospital or health care organization that provides drug abuse and/or alcoholism treatment services to adults or adolescents; CARF for programs affiliated with a residential treatment center that provides drug abuse and/or alcoholism treatment services to adults or adolescents. . Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 14: Page 172 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 15: ACCESS STANDARDS & ACCESS TO CARE Hoosier Healthwise: Anthem Medicaid Provider Helpline Phone: Hours of Operation: Healthy Indiana Plan: Anthem Provider Helpline Phone: Hours of Operation: 1-866-408-6132 Monday to Friday, 7am-7pm 1-800-345-4344 Monday to Friday, 7am-7pm Access Standards & Access to Care Overview This chapter outlines Anthem’s standards for timely and appropriate access to quality health care. Following guidelines set by the National Committee for Quality Assurance (NCQA), the American College of Obstetricians and Gynecologists (ACOG), and the Indiana Family and Social Services Administration (FSSA), these standards help ensure that medical appointments, emergency services and continuity of care for new and transferring Members are provided fairly, reasonably, and within specific time frames. We recognize that there can be cultural and linguistic barriers that affect our Members’ ability to understand or comply with certain instructions or procedures. In order to break through those barriers, we encourage Providers to review Anthem's Caring for Diverse Populations Toolkit which can be found under the Health Education heading on the Provider Resources page at www.anthem.com. Anthem monitors Provider compliance with access to care standards on a regular basis. Failure to comply may result in corrective action Access Standards & Access to Care Medical Appointment Standards: General Appointment Scheduling Primary Medical Providers and Specialists must make appointments for Members from the time of request as follows: Nature of Visit Appointment Standards Emergency Examinations Immediate Access During Office Hours Urgent Examinations Within 24 Hours of Request Non-Urgent "sick visits" Within 72 Hours of Request Non-Urgent routine exams* Within 21 days of Member's request Specialty Care Examinations Within 3 Weeks of Request Outpatient Behavioral Health Examinations Within 14 Days of Request Routine Behavioral Health Visits Within 10 Days of Request Outpatient Treatment Within 7 Days of Discharge Post-Psychiatric Inpatient Care Within 7 Days of Discharge *Exceptions are permitted for routine cases, other than clinical preventive services, when Primary Medical Provider capacity is temporarily limited. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 15: Page 173 Chapter 15: Access Standards and Access to Care Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Access Standards & Access to Care Medical Appointment Standards: Services for Members under the Age of 21 Anthem strongly recommends that Provider Medical Providers perform an Initial Health Assessment (IHA) and Preventive Care assessment with new Members. Please Note: An IHA is not needed if the Member is an existing patient of the Primary Medical Provider group (but new to Anthem). In addition, follow-up is not needed if there is an established medical record that shows baseline health status. This record should include sufficient information for the Primary Medical Provider to understand the Member’s health history and to provide treatment recommendations as needed. Transferred medical records meet the recommendations for an IHA if a completed health history is included. Nature of Visit Appointment Standards Initial Health Assessments Newborns: Within 14 Days of Enrollment Preventive Care Visits According to the American Academy of Pediatrics (AAP) Periodicity Schedule found within the Preventive Health Guidelines (PHG) Children: Within 60 Days of Enrollment Adults (18-21): Within 8 Weeks of Enrollment Access Standards & Access to Care Medical Appointment Standards: Services for Members 21 Years and Older Nature of Visit Appointment Standards Initial Health Assessments Within 90 Days of Enrollment Preventive Care Visits According to the American Academy of Pediatrics (AAP) Periodicity Schedule found within the Preventive Health Guidelines (PHG) Access Standards & Access to Care Medical Appointment Standards: Prenatal and Postpartum Visits Nature of Visit Appointment Standards First Trimester Within 14 Days of Request Second Trimester Within 7 Days of Request Third Trimester Within 3 Business Days of Request or Immediately if an Emergency High-Risk Pregnancy Within 3 Business Days of Request or Immediately if an Emergency Postpartum Exam Between 3-8 Weeks After Delivery Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 15: Page 174 Chapter 15: Access Standards and Access to Care Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Access Standards & Access to Care Medical Appointment Standards: Missed Appointment Tracking When Members miss appointments, Providers must do the following: Document the missed appointment in the Member’s medical record. Make at least 3 attempts to contact the Member to determine the reason for the missed appointment. Provide a reason in the Member’s medical record for any delays in performing an examination, including any refusals by the Member. Access Standards & Access to Care After-Hours Services Our Members have access to quality health care 24 hours a day, 7 days a week. That means Primary Medical Providers must have a system in place to ensure that Members can call after hours with medical questions or concerns. Anthem monitors Primary Medical Provider compliance with after-hours access standards on a regular basis. Failure to comply may result in corrective action. Primary Medical Providers must adhere to the following after-hours protocols: Answering service or after-hours personnel must: Forward Member calls directly to the Primary Medical Provider or on-call Provider or instruct the Member that the Provider will contact the Member within 30 minutes. Ask the Member if the call is an emergency. In the event of an emergency, they must immediately direct the Member to Dial 911 or proceed directly to the nearest hospital emergency room. Have the ability to contact a telephone interpreter for Members with language barriers. Return all calls. Members can also call the 24/7 NurseLine information phone line to speak to a registered nurse. Nurses provide health information and options for accessing care, including emergency services, if appropriate. Answering machine messages: May be used in the event that staff or an answering service is not immediately available. Must instruct Members with emergency health care needs to Dial 911 or proceed directly to the nearest hospital emergency room. Must provide instructions on how to contact the Primary Medical Provider or on-call Provider in a non-emergency situation. Must provide instructions in English, Spanish and any other language appropriate to the Primary Medical Provider’s practice. Please Note: Anthem prefers that Primary Medical Providers use an Anthem-contracted, in-network Provider for on-call services. When that is not possible, the Primary Medical Provider must use his or her best efforts to help ensure that the on-call Provider abides by the terms of the Anthem Provider contract. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 15: Page 175 Chapter 15: Access Standards and Access to Care Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Access Standards & Access to Care Continuity of Care Anthem provides continuity of care for Members with qualifying conditions when health care services are not available within the network or when the Member or Provider is in a state of transition. **Qualifying Condition: A medical condition that may qualify a Member for continued access to care and continuity of care. These conditions include, but are not limited to: Acute conditions (cancer, for example) Degenerative and disabling conditions, including conditions or diseases caused by a congenital or acquired injury or illness that require a specialized rehabilitation program or a high level of service, resources or coordination of care in the community Newborns, who are covered retroactive to the date of birth Organ transplant or tissue replacement Pregnancy, with 12 weeks or less remaining before the expected delivery date, through immediate postpartum care Scheduled inpatient/outpatient surgery that has been prior approved and/or pre-certified through the applicable Indiana Family and Social Services Administration (FSSA) process Serious chronic conditions (hemophilia, for example) Terminal illness States of transition may be any one of the following: The Member is newly enrolled The Member is moving out of the service area The Member is disenrolling from Anthem to another health plan The Member is exiting Hoosier Healthwise or the Healthy Indiana Plan to receive excluded services The Member is hospitalized on the effective date of transition The Member is transitioning through behavioral health services The Member is undergoing the Indiana Pre-Admission Screening/Resident Review Screening for long-term care placement The Member has appointments within the first month of Plan Membership with specialty Providers that were scheduled prior to the effective date of Membership The Provider’s contract terminates Anthem Providers help ensure continuity and coordination of care through collaboration. This includes the confidential exchange of information between Primary Medical Providers and Specialists as well as behavioral health Providers. In addition, Anthem helps coordinate care when the Provider's contract has been discontinued to help with a smooth transition to a new Provider. Providers must maintain accurate and timely documentation in the Member’s medical record including, but not limited to: Consultations Prior Authorizations Referrals to Specialists Treatment Plans Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 15: Page 176 Chapter 15: Access Standards and Access to Care Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan All Providers share responsibility in communicating clinical findings, treatment plans, prognosis and the Member’s psychosocial condition as part of the coordination process. Care management nurses review Member and Provider requests for continuity of care. These nurses facilitate continuation with the current Provider until a short-term regimen of care is completed or the Member transitions to a new practitioner. Please Note: Only Anthem can make adverse determination decisions regarding continuity of care. Adverse determination decisions are sent in writing to the Member and Provider within 2 business days of the decision. Members and Providers can appeal the decision by following the procedures in the Member Grievances and Appeals chapter in this manual. Reasons for continuity of care denials include, but are not limited to the following: Course of treatment is complete Member is ineligible for coverage Not a qualifying condition Request is for change of Primary Medical Provider only and not for continued access to care Requested services are not a covered benefit Services rendered are covered under a global fee Treating Provider is currently contracted with our network Please Note: Anthem does not impose any pre-existing condition limitations on its Medicaid Members, nor require evidence of insurability to provide coverage to any Anthem Member. Access Standards & Access to Care Provider Contract Termination Anthem will arrange for continuity of care for Members affected by a Provider whose contract is terminated. A terminated Provider who is actively treating Members must continue to treat Members until the Provider's date of termination. Primary Medical Providers must give at least 90 days advance notice and Specialists must give at least 120 days advance notice to Anthem before terminating the agreement unless the Primary Medical Provider or the group of Primary Medical Providers provides 30% or more of Anthem’s services. In that case, the Primary Medical Provider must give at least 120 days advance notice. Once Anthem receives a provider’s notice to terminate a contract, Anthem will make its best effort to notify all impacted Members. A letter will be sent at least 15 days in advance to inform the affected Members of: The impending termination of their Provider Their right to request continued access to care The Customer Care Center telephone number to make Primary Medical Provider changes and/or forward referrals to Case Management for continued access to care consideration Members under the care of Specialists may also submit requests for continued access to care, including continued care after the transition period. Members should contact the Customer Care Center at: 1-866-408-6131. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 15: Page 177 Chapter 15: Access Standards and Access to Care Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Access Standards & Access to Care Newly Enrolled Our goal is to ensure that the health care of our newly enrolled Members is not disrupted or interrupted. Anthem ensures continuity in the care of our newly enrolled Members when: The Member’s health or behavioral health condition has been treated by Specialists The Member’s health could be placed in jeopardy if medically necessary covered services are disrupted or interrupted Anthem will pay a newly enrolled Member’s existing out-of-network Provider for medically necessary covered services until that regimen of care is completed. The Member’s records, clinical information and care can then be transferred to an Anthem Provider. Payment to out-of-network Providers is made within the same time period required for those within the network. In addition, we will comply with out-of-network Provider reimbursement rules as adopted by the FSSA. However, we are not obligated to reimburse the Member’s existing out-of-network Providers for on-going care under the following conditions: More than 90 days after the Member enrolls in Anthem More than 9 months in the case of a Member who, at the time of enrollment in our plan, was diagnosed with and receiving treatment for a terminal illness and remains enrolled in our health care plan All new enrollees receive Evidence of Coverage (EOC) membership information in their enrollment packets. This also provides information regarding Members’ rights to request continuity of care. Access Standards & Access to Care Newly Enrolled - Pregnant Pregnancy services are covered by Hoosier Healthwise; they are not covered under the Healthy Indiana Plan. If a woman becomes pregnant while enrolled in the HIP, she must take the following steps: Submit proof of pregnancy to the state. Be removed from HIP, and get coverage under the Hoosier Healthwise program. Receive a prorated balance of her POWER Account upon leaving the HIP program. Following her pregnancy, she may enroll back in the Healthy Indiana Plan. The plan she chooses will be responsible for helping her with the transitions to assure seamless coverage. If a miscarriage occurs before a Healthy Indiana Plan member has moved to Hoosier Healthwise, the Healthy Indiana Plan will pay the related claims. Anthem will also go back and pay any other pregnancy related claims that have been denied due to the pregnancy exclusion. Providers should contact us through the Provider Helpline or submit a written request when there isn’t a claim submitted for spontaneous abortion or miscarriage to trigger adjustments of previous maternity related claims. Access Standards & Access to Care POWER Account Contributions and Change Information State subsidies make it possible for Healthy Indiana Plan Members to have health insurance by requiring minimal monthly contributions, based on income. These monthly contributions go into what is known as the Member's POWER Account. Combined with contributions from the state, the federal Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 15: Page 178 Chapter 15: Access Standards and Access to Care Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan government and the Member's employer, if applicable, POWER Account money is used to pay for health services until the Member's yearly deductible is met. Healthy Indiana Plan Members are required to make a contribution to their POWER Accounts every month. If an individual does not make a payment within 60 days, coverage is terminated. When coverage is terminated due to non-payment, in addition to losing Anthem medical coverage, the individual cannot reapply to the POWER Account program for 12 months. In addition, the following rules apply: If an individual chooses not to renew their Anthem coverage after 12 months in the plan, the individual may not reapply for the plan for at least 12 months. In addition, they will face a penalty on the remaining balance of their POWER Account and will not be able to receive the full proportional balance of their contribution. Participants may request one change to their POWER Account contribution during the 12-month term of their plan if they have a “qualifying event.” Examples of qualifying events include loss of job or reduction of work hours. POWER Account updates due to changes in family size will be considered at any time. Such changes include marriage, divorce, legal separation, birth or death. The state will make its entire contribution at the time of enrollment to ensure money will be in the account on the Member’s effective date. The state will advance payment to the Provider for the service, and then deduct the amount from the POWER Account when future contributions are made. Individuals are still responsible for these “advance payments.” Access Standards & Access to Care Members Moving Out of Service Area If a Member moves out of the service area, Anthem will continue to provide services and pay out-ofnetwork Providers for the specific period of time left for which capitation on the Member has been paid. That means that if a Member’s capitation covers the month of June, Anthem will provide and pay for medically necessary covered services through the end of that month. Access Standards & Access to Care Services Not Available Within Network Anthem will provide Members with timely and adequate access to out-of-network services for as long as those services are necessary and not available within the network. However, Anthem is not obligated to provide Members with access to out-of-network services if such services become available from a network Provider. When a Provider refers a Member to another Provider for additional treatment or services, the referring Provider must forward notification of their Provider identifier and the Member’s eligibility. Anthem has streamlined this process by providing a Record of Referral to Specialty Care form, which is located the Forms Library on the Providers Resources page at: www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. The referring Primary Medical Provider and the Specialist should follow these steps: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 15: Page 179 Chapter 15: Access Standards and Access to Care Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The Primary Medical Provider should fax the form to the Specialist to ensure that the Specialist has the Primary Medical Provider's NPI. If the referring Primary Medical Provider’s NPI number is not provided, the Specialist will be responsible for contacting the Primary Medical Provider’s office to obtain it. The Member must be made aware that the Provider they are being referred to is in-network or outof-network. Please Note: Referrals are valid for as long as the Member is under the care of the Specialist. Access Standards & Access to Care Second Opinions Anthem will help ensure that Members have access to a second opinion regarding any medically necessary covered service. Members will be allowed access to a second opinion from a network Provider, or, if a network Provider is not available, from an out-of-network Provider. This service is provided at no cost to the Member. Access Standards & Access to Care Emergency Transportation Anthem covers emergency transportation services without Prior Authorization. When a Member’s condition is life-threatening and requires use of special equipment, life support systems and close monitoring by trained attendants while en route to the nearest appropriate facility, we will provide emergency transport by ambulance. Examples of conditions considered for emergency transport include, but are not limited to: Acute and severe illnesses Acute or severe injuries from auto accidents Extensive burns Loss of consciousness Semi-consciousness, having a seizure or receiving cardiopulmonary resuscitation (CPR) treatment during transport Untreated fractures Emergency transportation also is available for facility-to-facility transfers when the required emergency treatment is not available at the first facility. Access Standards & Access to Care Non-Emergency Transportation Non-emergency transportation is a covered service for both Hoosier Healthwise and Healthy Indian Plan. Limited non-emergency transportation will be provided by a certified ambulance, taxi or other certified transportation providers, including: Commercial ambulatory services Non-ambulatory services Transportation by a registered family member Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 15: Page 180 Chapter 15: Access Standards and Access to Care Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan A copayment may apply. Members enrolled in Hoosier Healthwise are allowed an unlimited numbers of trips. Members enrolled in Healthy Indiana Plan are limited to 20 one-way trips, up to 50 miles per trip, in a rolling 12-month period, with the following exceptions: Transporting Member to hospital for admission Transporting Member home after discharge Inter-hospital transportation for admission to another hospital Transporting Member from a non-network provider to a network provider. Members on renal dialysis or living in nursing homes Access Standards & Access to Care Emergency Dental Services – Adults & Children When a Member has a dental-related accident and requires repair of an injury to the jaw, sound natural teeth, mouth or face, Anthem covers the initial dental work and oral surgery, including anesthesia and drugs, for services provided in the following settings: Outpatient Doctor's office Emergency care Urgent care The services are limited to the care needed to give proper treatment. Injury as a result of chewing or biting is not considered an accidental injury. Initial dental work refers to services provided within 48 hours of the injury, or as soon as possible. Covered services include all exams and treatment to complete the repair, such as: Anesthesia Lab tests Mandibular/Maxillary reconstruction Oral exams Oral surgery Prosthetic services Restorations X-Rays Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 15: Page 181 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 16: PROVIDER ROLES & RESPONSIBILITIES Hoosier Healthwise Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Provider Roles & Responsibilities Overview At Anthem, our goal is to provide quality health care to the right Member, at the right time, in the appropriate setting. To achieve this goal, Primary Medical Providers, Specialists and Ancillary Providers must fulfill their roles and responsibilities with the highest integrity. We lean on their extensive health care education and experience and rely on their dedication to our Members who, in turn, look to them to get well and stay well. Provider Roles & Responsibilities Primary Medical Providers Anthem's Primary Medical Providers are the principle point of contact for our Members. Their role is to provide Members with a medical “home,” their first stop in the health care process and a centralized hub for a wide variety of ongoing health care needs. Anthem furnishes each Primary Medical Provider with a current list of enrolled Members assigned to that Primary Medical Provider. The Primary Medical Provider’s role is to: Coordinate a Member’s health care, 24 hours a day, 7 days a week Develop the Member’s care and treatment plan, including preventive care Maintain the Member's current medical record, including documentation of all services provided by the Primary Medical Provider and any specialty or referral services Adhere to wait times, as outlined within the Provider contract and Provider Manual Refer Members for specialty care Coordinate with outpatient clinical services Provide complete information about proposed treatments and prognosis for recovery to our Members or their representatives Facilitate interpreter services by presenting information in a language that our Members or their representatives can understand Ensure that Members' medical and personal information is kept confidential as required by state and federal laws Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 16: Page 182 Chapter 16: Provider Roles & Responsibilities Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The Primary Medical Provider’s scope of responsibilities includes providing or arranging for: Routine and preventive health care services Emergency care services Hospital services Ancillary services Specialty referrals Interpreter services Coordination with outpatient clinical services, such as therapeutic, rehabilitative or palliative services Please note: Services should always be provided without regard to race, religion, sex, color, national origin, age, or physical/behavioral health status. Anthem Members select a contracted Primary Medical Provider as their primary Provider of health care services within the first 14 calendar days of the Member's effective date of enrollment. If, after 14 calendar days, the Member has not selected a Primary Medical Provider, Anthem will assign a Primary Medical Provider to the Member. We keep Providers up-to-date with detailed Member information. Anthem furnishes each Primary Medical Provider with a current list of assigned Members and, from time to time, provides medical information about the Members’ potential health care needs. That way, Providers can more effectively provide care and coordinate services. Primary Medical Providers See Only Assigned Members Please remember that when seeing Anthem Members enrolled in Hoosier Healthwise or the Healthy Indiana Plan, you should provide service only to those Members who have chosen you are their Primary Medical Provider. You can confirm that a Member is assigned to you by: Calling the Anthem Medicaid Provider Helpline: 1-866-408-6132 or the Anthem Provider Helpline: 1-800-345-4344 Use the Interactive Voice Response (IVR) system to verify Primary Medical Provider assignment Speak to a customer service representative Log into MyAnthem, located at www.anthem.com to see monthly Primary Medical Provider rosters. You may experience delays in claims payments if you treat Members who are not assigned to you on the date of service. If it is necessary to provide services to an Anthem Member not assigned to you, it is important to get authorization before providing services. If you are a non-contracted Provider, you will need to obtain prior authorization before providing services to our Members. Provider Roles & Responsibilities Referrals Primary Medical Providers coordinate and make referrals to Specialists, Ancillary Providers and community services. Providers should refer Members to network facilities and Providers. When this is not possible, Providers should follow the appropriate process for requesting out-of-network referrals. Please Note: Specialty referrals to network Providers do not require prior authorization. All Primary Medical Providers: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 16: Page 183 Chapter 16: Provider Roles & Responsibilities Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Are expected to help Members schedule appointments with other health care Providers, including Specialists. Are expected to track and document appointments, clinical findings, treatment plans and care received by Members referred to Specialists or other health care Providers to ensure continuity of care. Are expected to refer Members to health education programs and community resource agencies, when appropriate. Must coordinate with the Woman, Infants and Children (WIC) program to provide medical information necessary for WIC eligibility determinations, such as height, weight, hematocrit or hemoglobin. Coordinate with the local tuberculosis (TB) control program to ensure that all Members with confirmed or suspected TB have a contact investigation and receive Directly Observed Therapy (DOT). Report to the Indiana Family and Social Services Administration (FSSA) or the local TB control program any Member who is noncompliant, drug resistant or who is or may be posing a public health threat. Are responsible for screening and evaluation procedures for detection and treatment of, or referral for, any known or suspected behavioral health problems and disorders. Provider Roles & Responsibilities Out-Of-Network Referrals We recognize that there may be instances when an out-of-network referral is justified. Anthem’s Care Management (UM) team will work with the Primary Medical Provider to determine medical necessity; after that, out-of-network referrals will be authorized on a limited basis. The UM department may be contacted at: Hoosier Healthwise: 1-866-408-7187 (Monday to Friday, 8am-5pm) Healthy Indiana Plan: 1-866-398-1922 (Monday to Friday, 8:30am-5pm) Provider Roles & Responsibilities Interpreter Services Providers must notify Members of the availability of interpreter services and strongly discourage the use of friends and family members, especially children, acting as interpreters. Multi-lingual staff should selfassess their non-English language speaking and understanding skills prior to interpreting on the job. You can find the current recommended employee language skills self-assessment tool on in the Forms Library on the Providers Resources page at: www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. For those instances when you cannot communicate with a Member due to language barriers, interpreter services are available at no cost to you or the Member. Face-to-face interpreters for Members needing language assistance, including American Sign Language, are available by placing a request at least 72 hours in advance. A 24-hour cancellation notice is required. To request interpreter services, Providers and Members should call: Anthem Medicaid Provider Helpline: 1-866-408-6132 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 16: Page 184 Chapter 16: Provider Roles & Responsibilities Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Customer Care Center (Members): 1-866-408-6131 Providers can also email their request for a face to face interpreter by using the address in the Interpreter Services section of the Provider Resources portal. Provider Roles & Responsibilities Initial Health Assessment Primary Medical Providers are strongly encouraged to review their monthly eligibility list provided by Anthem and proactively contact their assigned Members to make an appointment for an Initial Health Assessment (IHA). These appointments should occur within the following time frames: Newborns: Within 14 Days of Enrollment Children: Within 60 Days of Enrollment Adults (18-21): Within 8 Weeks of Enrollment The Primary Medical Provider’s office is responsible for making and documenting all attempts to contact assigned Members. Members’ medical records must reflect the reason for any delays in performing the IHA, including any refusals by the Member to have the exam. Provider Roles & Responsibilities Transitioning Members between Facilities or Back Home Primary Medical Providers initiate or help with the discharge or transfer of: Members at an inpatient facility to the appropriate level of care facility (including skilled nursing or rehabilitation facility) when medically indicated, or home Members who are hospitalized in an out-of-network facility to an in-network facility, or to home with home health care assistance (within benefit limits) when medically indicated The coordination of Member transfers from non-contracted out-of-network facilities to contracted innetwork facilities is a priority that may require the immediate attention of the Primary Medical Provider. Contact Anthem’s Care Management to assist in this process: Hoosier Healthwise: 1-866-408-7187 (Monday to Friday, 8am-5pm) Healthy Indiana Plan: 1-866-398-1922 (Monday to Friday, 8:30am-5pm) Provider Roles & Responsibilities Specialists Specialists, licensed with additional training and expertise in a specific field of medicine, supplement the care given by Primary Medical Providers and are charged with the same responsibilities. That includes the responsibility for ensuring that necessary prior authorizations have been obtained before providing services. Access to specialty care begins in the Primary Medical Provider’s office. The Primary Medical Provider will refer a Member to a Specialist for conditions beyond the Primary Medical Provider’s scope of practice that are medically necessary. Specialists diagnose and treat conditions specific to their area of expertise. Please Note: Specialty care is limited to Anthem benefits. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 16: Page 185 Chapter 16: Provider Roles & Responsibilities Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The following guidelines are in place for Specialists Providers: For urgent care, the Specialist should see the Member within 24 hours of receiving the request. For routine care, the Specialist should see the Member within 2 weeks of receiving the request. In some cases, a Member may self-refer to a Specialist. These cases include, but are not limited to: Family planning and evaluation Diagnosis, treatment and follow-up of Sexually Transmitted Infections (STIs) Please Note: Specialists are responsible for ensuring that necessary pre-authorizations have been obtained prior to providing services. For some medical conditions, it makes sense for the Specialist to be the Primary Medical Provider. Members may request that the Specialist be assigned as the Primary Medical Provider if: The Member has a chronic illness The Member has a disabling condition The Member is a child with special health care needs Provider Roles & Responsibilities Behavioral Health Providers For information about Anthem’s Behavioral Health providers, please see Chapter 5: Behavioral Health Services. Provider Roles & Responsibilities Behavioral Health Providers – Transition after Acute Psychiatric Care For information about Anthem’s Behavioral Health transition after acute psychiatric care, please see Chapter 5: Behavioral Health Services. Provider Roles & Responsibilities Hospital Scope of Responsibilities Primary Medical Providers refer Members to Plan-contracted network hospitals for conditions beyond the Primary Medical Provider’s scope of practice that are medically necessary. Hospital care is limited to Plan benefits. Hospital professionals diagnose and treat conditions specific to their area of expertise. Hospital responsibilities include the following: Notification of Admission and Services The hospital must notify Anthem or the review organization of an admission or service at the time the Member is admitted or service is rendered. If the Member is admitted or a service is rendered on a day other than a business day, the hospital must notify Anthem of the admission or service the morning of the next business day following the admission or service. Notification of Pre-service Review Decision If the hospital has not received notice of pre-service review determination at the time of a scheduled admission or service, as required by the Utilization Management Guidelines and the Hospital Agreement, the hospital should contact Anthem and request the status of the decision. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 16: Page 186 Chapter 16: Provider Roles & Responsibilities Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Any admission or service that requires pre-service review, as discussed in the Utilization Management Guidelines and the Hospital Agreement, and has not received the appropriate review, may be subject to post-service review denial. Generally, the Provider is required to perform all pre-service review functions with Anthem; however, the hospital may ensure, before services are rendered, that such has been performed, or risk post-service denial. Provider Roles & Responsibilities Ancillary Scope of Responsibilities Primary Medical Providers and Specialists refer Members to Plan-contracted network ancillary professionals for conditions beyond the Primary Medical Provider’s or Specialist’s scope of practice that are medically necessary. Ancillary professionals diagnose and treat conditions specific to their area of expertise. Ancillary care is limited to Plan benefits. Anthem has a wide network of participating health care professionals and facilities. All services provided by the health care professional, and for which the health care professional is responsible, are listed in the Ancillary Agreement. Provider Roles & Responsibilities Responsibilities Applicable to ALL Providers There are a number of responsibilities applicable to all Anthem Providers. They include: After-Hours Services Disenrollees Eligibility Verification Collaboration Confidentiality Continuity of Care Licenses and Certifications Mandatory Reporting of Abuse Medical Records Standards & Documentation Office Hours Open Clinical Dialog/Affirmative Statement Oversight of Non-Physician Practitioners Pre-Service Reviews Prohibited Activities Provider Contract Terminations Termination of Ancillary Provider/Patient Relationship Updating Provider Information Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 16: Page 187 Chapter 16: Provider Roles & Responsibilities Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Provider Roles & Responsibilities Office Hours To maintain continuity of care, Providers’ office hours must be clearly posted and Members must be informed about the Provider’s availability at each site. There are strict guidelines for providing access to health care 24 hours a day, 7 days a week: Providers must be available 24 hours a day by telephone. During those times when a Provider is not available, an on-call Provider must be available to take calls. Provider Roles & Responsibilities After-Hours Services All Primary Medical Providers must have an after-hours system in place to ensure that our Members can call with medical concerns or questions after normal office hours. The answering service or after-hours personnel must forward Member calls directly to the Primary Medical Provider or on-call physician, or instruct the Member that the Provider will contact him or her within 30 minutes. Emergencies The answering service or after-hours personnel must ask the Member if the call is an emergency. In the event of an emergency, the Member must be immediately directed to dial 911 or to proceed directly to the nearest hospital emergency room. If the Primary Medical Provider’s staff or answering service is not immediately available, an answering machine may be used. The answering machine message must instruct Members with emergency health care needs to dial 911 or go directly to the nearest hospital emergency room. The message must also give Members an alternative contact number so they can reach the Primary Medical Provider or on-call Provider with medical concerns or questions. Language-Appropriate Messages Non-English speaking Members who call their Primary Medical Provider after hours should expect to get language appropriate messages. In the event of an emergency, these messages should direct the Member to dial 911 or proceed directly to the nearest hospital emergency room. In a non-emergency situation, Members should receive instruction on how to contact the on-call Provider. If an answering service is used, the service should know where to contact a telephone interpreter for the Member. All calls taken by an answering service must be returned. Network On-Call Providers Anthem prefers that Primary Medical Providers use network Providers for on-call services. When that is not possible, the Primary Medical Provider must help ensure that the covering on-call physician or other professional provider abides by the terms of the Anthem Provider contract. Anthem will monitor Primary Medical Provider compliance with after-hours access standards on a regular basis. Failure to comply may result in corrective action. Members can also call the 24/7 NurseLine information line, 24 hours a day, seven days a week, to speak to a registered nurse. These nurses provide health information regarding illness and options for accessing care, including emergency services. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 16: Page 188 Chapter 16: Provider Roles & Responsibilities 24/7 NurseLine: Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan 1-866-800-8780 (24 hours a day, 7 days a week) 1-800-368-4424 (TTY) Provider Roles & Responsibilities Licenses and Certifications Providers must maintain all licenses, certifications, permits, accreditations or other prerequisites required by Anthem and federal, state and local laws to provide medical services. Provider Roles & Responsibilities Eligibility Verification All Providers must verify Member eligibility immediately by using Availity and web interchange before providing services, supplies or equipment. Eligibility may change monthly so a Member eligible on the last day of the month may not be eligible on the first of the following month. Anthem is not responsible for charges incurred by ineligible persons. Provider Roles & Responsibilities Collaboration Providers share the responsibility of giving respectful care, working collaboratively with Anthem Specialists, hospitals, Ancillary Providers and Members and their families. Providers must permit Members to participate actively in decisions regarding medical care, including, except as limited by law, their decision to refuse treatment. The Provider also facilitates interpreter services and provides information about the Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) program. Provider Roles & Responsibilities Continuity of Care The Primary Medical Provider maintains frequent communication with Specialists, hospitals and Ancillary Providers to ensure continuity of care. Anthem encourages Providers to maintain open communication with their patients regarding appropriate treatment alternatives, regardless of their benefit coverage limitations. The Primary Medical Provider is responsible for providing an ongoing source of primary care appropriate to the Member’s needs. Anthem has established comprehensive mechanisms to ensure continued access to care for Members when Providers leave our health care program. Under certain circumstances, Members may finish a course of treatment with the terminating Provider. For more information, refer to the Access Standards chapter. Provider Roles & Responsibilities Medical Records: Standards Medical records must be maintained in a manner that ensures effective and confidential Member care and quality review. At Anthem, we perform medical record reviews upon signing a Provider contract and, at minimum, every 3 years thereafter to ensure that Providers are in compliance with these standards. Medical records must be stored and retrieved in a manner that protects patient information according to the Confidentiality of Medical Information Act. This act prohibits a provider of health care from Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 16: Page 189 Chapter 16: Provider Roles & Responsibilities Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan disclosing any individually identifiable information regarding a patient’s medical history, treatment, or behavioral and physical condition, without the patient’s or legal representative’s consent or specific legal authority. Records required through a legal instrument may be released without patient or patient representative consent. Providers must be familiar with the security requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and be in compliance. For more information on medical records standards, please refer to our chapter on Access Standards. Provider Roles & Responsibilities Mandatory Reporting of Child Abuse, Elder Abuse or Domestic Violence Providers must ensure that their office staff knows about local reporting requirements and procedures to make telephone and written reports of known or suspected cases of abuse. All health care professionals must immediately report actual or suspected child abuse, elder abuse or domestic violence to the local law enforcement agency by telephone. In addition, Providers must submit a followup written report to the local law enforcement agency within the time frames as required by law. Provider Roles & Responsibilities Updating Provider Information Anthem network Providers are required to inform us of any material changes to their practice, including: Change in professional business ownership Change in business address or the location where services are provided Change in federal 9-digit Tax Identification Number (TIN) Change in specialty If the Provider provides services to children Languages spoken Change in demographic data (for example: phone numbers, languages of Providers and/or office personnel) Legal or governmental action initiated against a health care professional. This includes, but is not limited to, an action for professional negligence, for violation of the law, or against any license or accreditation which, if successful, would impair the ability of the health care professional to carry out the duties and obligations under the Provider Agreement Other problems or situations that may impair the ability of the health care professional to carry out the duties and obligations under the Provider Agreement care review and grievance resolution procedures Notification that the Provider is accepting new patients Notify Anthem of changes by using the Provider Maintenance Form for Professional Providers, which is available on our website: www.anthem.com. Facility and Ancillary Provider submit changes on company letterhead to your Anthem contractor. If Anthem determines that the quality of care or services provided by a health care professional is not satisfactory, as evidenced by Member satisfaction surveys, Member complaints or grievances, utilization Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 16: Page 190 Chapter 16: Provider Roles & Responsibilities Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan management data, complaints or lawsuits alleging professional negligence, or any other quality of care indicators, Anthem may terminate the Provider Agreement. Provider Roles & Responsibilities Oversight of Non-Physician Practitioners All Providers using non-physician practitioners must provide supervision and oversight of non-physician practitioners consistent with state and federal laws. The supervising physician and the non-physician practitioner must have written guidelines for adequate supervision, and all supervising providers must follow state licensing and certification requirements. Non-physician practitioners include the following categories: Advanced Registered Nurse Practitioners Certified Nurse Midwives Physician Assistants These non-physician practitioners are licensed by the state and working under the supervision of a licensed physician as mandated by state and federal regulations. Provider Roles & Responsibilities Open Clinical Dialogue/Affirmative Statement Nothing within the Provider’s Provider Agreement or this Provider Manual should be construed as encouraging Providers to restrict medically necessary covered services or limit clinical dialog between Providers and their patients. Providers may communicate freely with Members regarding the treatment options available to them, including medication treatment options, regardless of benefit coverage limitations. Provider Roles & Responsibilities Provider Contract Termination A terminated Provider who is actively treating Members must continue to treat Members until the Provider’s date of termination. That date is the end of the 90-day period following written notice of termination, or time lines determined by the medical group contract. Once we receive a Provider’s notice to terminate a contract, we notify Members impacted by the termination. Anthem sends a letter to inform affected Members of: The impending termination of their Provider Their right to request continued access to care The Customer Care Center telephone number to make Primary Medical Provider changes Referrals to Utilization Management for continued access to care consideration Members under the care of Specialists can also submit requests for continued access to care, including continued care after the transition period, by calling the Customer Care Center. Member Customer Care Center: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan 1-866-408-6131 1-866-408-7188 (TTY) Version 2.2 June 1, 2014 Chapter 16: Page 191 Chapter 16: Provider Roles & Responsibilities Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Provider Roles & Responsibilities Termination of the Ancillary Provider/Patient Relationship Under certain circumstances, an Ancillary Provider may terminate the professional relationship between the Ancillary Provider and a Member as provided for and in accordance with the provisions of this manual. However, Ancillary Providers may not terminate the relationship because of the Member’s medical condition or the amount, type or cost of covered services required by the Member. Provider Roles & Responsibilities Disenrollees When a Member disenrolls and requests transfer to another health plan, Providers are expected to work with the Anthem case managers who are responsible for helping the Member make the transition. This transition must occur without disruption of any regimen of care that qualifies as a Continuity of Care condition. The case manager will coordinate with the Member, the Member’s Providers and the case manager at the new health plan to help ensure an orderly transition. Provider Roles & Responsibilities Provider Rights Anthem network Providers, acting within the lawful scope of practice, shall not be prohibited from advising a Member or advocating on behalf of a Member for any of the following: The Member's health status, medical care or treatment options, including any alternative treatment that may be self-administered Any information the Member needs in order to decide among all relevant treatment options The risks, benefits and consequences of treatment or non-treatment The Member's right to participate in decisions regarding their health care, including the right to refuse treatment and to express preferences about future treatment decisions To receive information on the Grievances & Appeals and State Fair Hearing procedures To have access to policies and procedures covering authorization of services To be notified of any decision to deny a service authorization request, or to authorize a service in an amount, duration or scope that is less than requested To challenge, on behalf of our Members, the denial of coverage, or payment for, medical assistance To be free from discrimination for the participation, reimbursement or indemnification of any Provider who is acting within the scope of his/her license or certification under applicable law solely based on that license or certification Anthem's network Provider selection policies and procedures do not discriminate against particular Providers who serve high-risk populations or specialize in conditions that require costly treatment. Provider Roles & Responsibilities Prohibited Activities All Providers are prohibited from: Billing eligible Members for covered services Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 16: Page 192 Chapter 16: Provider Roles & Responsibilities Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Segregating Members in any way from other persons receiving similar services, supplies or equipment Discriminating against Anthem Members or Medicaid participants Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 16: Page 193 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 17: CLINICAL PRACTICE AND PREVENTIVE HEALTH CARE GUIDELINES Hoosier Healthwise Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-8pm Clinical Practice and Preventive Health Care Guidelines Overview At Anthem, we believe that providing quality health care shouldn't be limited to the treatment of injury or illness. We are committed to helping Providers and Members become more pro-active in the quest for better overall health. To accomplish that goal, we offer Providers tools to help them find the best, most cost-effective ways to: Provide Member treatment Empower Members through education Encourage Member lifestyle changes where possible We want Providers to have access to the most up-to-date clinical practice and preventive health care guidelines. These guidelines, offered by nationally recognized health care organizations and based on extensive research, include the latest standards for treating the most common, stubborn and serious illnesses, such as diabetes and hypertension. They also include guidelines for preventive screenings, immunizations and Member counseling based on age and gender. Clinical Practice and Preventive Health Care Guidelines Preventive Health Care Guidelines Anthem considers prevention an important component of health care. Anthem develops preventive health guidelines in accordance with recommendations made by nationally recognized organizations and societies such as the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the Advisory Committee on Immunizations Practices (ACIP), the American College of Obstetrics and Gynecology (ACOG) and the United States Preventive Services Task Force (USPSTF). The above organizations make recommendations based on reasonable medical evidence. We review the guidelines annually for content accuracy, current primary sources, new technological advances and recent medical research and make appropriate changes based on this review of the recommendations and/or preventive health mandates. We encourage physicians to utilize these guidelines to improve the health of our Members. The guidelines, educational materials and health management programs can be found under the Quality Improvement Program heading on the Provider Resources page of our website, www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 17: Page 194 Chapter 17: Clinical Practice & Preventive Health Care Guidelines Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The website offers the most up-to-date clinical resources for preventive screenings, immunizations and counseling for our Members. If you do not have Internet access, you can request a hard copy of the Preventive Health Care Guidelines by calling our Provider Helpline at: Hoosier Healthwise: 1-866-408-6132 Healthy Indiana Plan: 1-800-345-4344 Please Note: With respect to the issue of coverage, each Member should review his or her Certificate of Coverage and Schedule of Benefits for details concerning benefits, procedures and exclusions prior to receiving treatment. The Member Handbook supersedes the preventive health guidelines. Clinical Practice and Preventive Health Care Guidelines Clinical Practice Guidelines Anthem considers clinical practice guidelines an important component of health care. Anthem adopts nationally recognized clinical practice guidelines and encourages physicians to utilize these guidelines to improve the health of our Members. Several national organizations produce guidelines for asthma, diabetes, hypertension and other conditions. The guidelines, which Anthem uses for quality and disease management programs, are based on reasonable medical evidence. We review the guidelines at least every two years or when changes are made to national guidelines for content accuracy, current primary sources, new technological advances and recent medical research. You can access the Clinical Practice Guidelines under the Quality Improvement Program heading on the Provider Resources page of our website, www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. The website offers the most up-to-date clinical resources and guidelines. If you do not have Internet access, you can request a hard copy of the Clinical Practice Guidelines by calling our Provider Helpline at: Hoosier Healthwise: 1-866-408-6132 Healthy Indiana Plan: 1-800-345-4344 Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 17: Page 195 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 18: CASE MANAGEMENT Case Management Phone: Case Management Fax: Hours of Operation: 1-866-408-7187 1-866-387-2959 Monday to Friday, 8am-5pm WIC: Breastfeeding Support Line: Access to Care Fax: 1-800-522-0874 1-800-231-2999 1-877-604-0476 Case Management Overview Case Management is a process that emphasizes collaborative, multidisciplinary teamwork to develop, implement, coordinate and monitor treatment plans in order to optimize our Members’ health care benefits. Anthem’s case management program, provided at no cost to Providers and Members, offers expert assistance in the coordination of complex health care, including the integration of physical and behavioral health needs. The case manager, through partnership with Providers and Members, collects data and analyzes information about actual and potential care needs for the purpose of developing a treatment plan. Cases referred to case management may be identified by disease or condition, dollars spent or high utilization of services. Please Note: The Anthem Case Management team is sensitive to cultural diversity and the impact it has on our Members and their interaction within the health care system. We encourage Providers to become familiar with our cultural and linguistic training materials, available under Health Education: Caring for Diverse Populations on the Provider Resources page of our website, www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Interpreter services are available at no cost to support the Case Management process. Case Management Role of the Case Manager The case manager’s role is to assess the Member’s health care status, develop a health care plan and: Facilitate communication and coordination within the health care team. Facilitate communication with the Member and his or her family in the decision-making process. Educate the Member and Providers on the health care team about care management, community resources, benefits, cost factors and all related topics so that informed decisions can be made. Encourage appropriate use of medical facilities and services, with the goal of improving quality of care and maintaining cost-effectiveness on a case-by-case basis. The case management team includes experienced and credentialed registered nurses, many of whom are Certified Case Managers (CCMs). The team also includes social workers. The case manager social workers add valuable skills that allow us to address not only our Members’ medical needs, but also their psychological, social and financial issues. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 18: Page 196 Chapter 18: Case Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Case Management Provider Responsibility Providers have the responsibility to participate in the case management process by sharing information and facilitating the process by: Referring Members who could benefit from case management. Sharing information as soon as possible and as early as the Initial Health Assessment if the Primary Medical Provider identifies complex health care needs. Collaborating with case management staff on an ongoing basis. Recommending referrals to Specialists, as required. Monitoring and updating the care plan to promote health care goals. Notifying Case Management if Members are referred to services provided by the state or some other institution not covered by the Anthem agreement. Coordinating county or state-linked services such as public health, behavioral health, schools and waiver programs. The Provider may call Case Management for additional assistance for : Hoosier Healthwise Members who are enrolled in the Individualized Family Services Plan (IFSP), Providers should notify us of special needs children who would benefit from case management and are responsible for coordinating with Anthem and Indiana's Family and Social Services Administration's (FSSA) First Steps System. First Steps provides early intervention services for children from birth to three years of age who are experiencing developmental delays and/or have a diagnosed condition that has a high probability of resulting in developmental delays. Hoosier Healthwise Members involved in the state's Individualized Education Plan (IEP), which provides services to special needs students, including physical therapy, speech pathology, audiology, school nursing and rehabilitation counseling. Anthem network Providers are responsible for communicating and coordinating with the school to ensure continuity of care and avoid duplication of services. Case Management Procedures When a Member has been identified as having a condition that may benefit from case management, the case manager contacts the referring Provider and Member for input on completion of an initial assessment. Then, with the involvement of the Member, the Member’s representative and the Provider, the case manager develops an individualized care plan. That plan may involve coordinating services with public and behavioral health departments, schools and other community health resources. The case manager periodically re-assesses the care plan to monitor the following: Progress toward goals Necessary revisions New issues that need to be addressed to help ensure that the Member receives the support needed to achieve care plan goals Once goals are met or case management can no longer impact the case, the case manager closes the Member’s case. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 18: Page 197 Chapter 18: Case Management Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Case Management Potential Referrals Providers, nurses, social workers and Members or their representatives may request case management services. Examples of cases appropriate for referral include: Adults with special health care needs requiring coordination of care Auto-immune diseases such as HIV/AIDS Children with special health care needs Chronic illness such as asthma, diabetes and heart failure Complex or multiple-care needs such as multiple trauma or cancer Frequent hospitalizations or emergency room utilization Hemophilia, sickle cell anemia, cystic fibrosis, cerebral palsy Spinal injuries High-risk pregnancies Potential transplants Pre-term births (Hoosier Healthwise only) Case Management Referral Process Providers, nurses, social workers and Members or their representative may refer Members to Case Management in one of two ways: Phone: 1-866-408-7187 Fax: 1-866-387-2959 A case manager will respond to a faxed request within 3 business days. Case Management Accessing Specialists Case managers are available to assist Primary Medical Providers with access to Specialists. Please Note: Standing referrals or an approved number of visits for access to in-network Specialists do not require prior authorization. Referrals to out-of-network Specialists do require prior authorization. Case Management Behavioral Health Case Management Anthem ensures the integration of physical and behavioral health care management. For information about Behavioral Health Case Management, please see Chapter 5: Behavioral Health Services. Case Management Behavioral Health Clinical Authorization and Protocols For information about Anthem’s Behavioral Health clinical authorization and protocols, please see Chapter 5: Behavioral Health Services. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 18: Page 198 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 19: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Hoosier Healthwise Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-8pm Quality Assessment and Performance Improvement Overview The goal of Anthem Blue Cross and Blue Shield (Anthem) is continuous, measurable improvement in the delivery of, and access to high quality health care. Following regulatory and accrediting body requirements, we have a Quality Assessment and Performance Improvement (QAPI) program to monitor and evaluate the quality, safety and appropriateness of medical and behavioral health care and service offered by the health network. The QAPI program also serves to identify and act on opportunities for improvement. The Anthem Board of Directors (BOD) are responsible for organizational governance and have final authority and accountability for the QAPI program. The BOD delegates responsibility for development and implementation of the QAPI program to the Medicaid Quality Oversight Committee (QOC). External advisory guidance is sought to provide external input into internal programming. Service and operations committees also work together to coordinate clinical and service quality improvement activities. Quality Management Leadership has day-to-day oversight of the QAPI program. There are quality processes in place throughout the enterprise in order to maintain the connection with the local Members, Providers and community. The QOC reviews and approves the annual quality program documents, including the QAPI program description, QI Work Plan and the QAPI program’s annual evaluation. The results of the annual QAPI Evaluation are used to develop and prioritize the next year’s annual QI Work Plan. The QAPI program is collaborative in nature and includes focused studies and reviews that measure quality of care in specific clinical and service areas. Providers are expected to participate to help us achieve our goal of providing responsive, safe and cost-effective health care that makes a difference in our Member’s lives. Program Monitoring To enable comprehensive assessment of the Plan’s health system and meaningful prioritization of initiatives, Anthem selects critical monitors from the QAPI program components inherent to the promotion of quality clinical care and service including: • Accessibility of Services Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan • Health Equities and Cultural and Linguistic Services Version 2.2 June 1, 2014 Chapter 19: Page 199 Chapter 19: Quality Assessment & Performance Improvement Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan • Availability of Practitioners • Health Services Programs • Behavioral Health • Maternity Management • CAHPS®1 Member Satisfaction Survey • Medical Record Review • Preventive Health Guidelines • Member, Practitioner and Provider Communications • Clinical Practice Guidelines for Medical and Behavioral Health • Patient Safety • Complaints, Grievances and Appeals • Pharmacy and Therapeutics • Continuity/Coordination of Care • Provider Credentialing/Recredentialing • Contracting • Provider Satisfaction • Facility Site Review • Utilization and Case Management • ®2 HEDIS ® 1. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). ® 2. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Internally, areas to monitor are selected by identifying aspects of care and/or service that are high in volume, risk, or problem-prone. Selections are based on the probability that the review will have a positive impact on members’ health and well-being. Priority is given those areas with issues related to major population groups, members’ health risks, and where actions are likely to have the greatest member impact. Externally, states may require certain clinical measures to achieve a specific benchmark, or will provide incentives/performance guarantees for individual measures. Also, the Centers for Medicare & Medicaid Services (CMS) in conjunction with the State of Indiana, may specify performance measures and topics for Performance Improvement Projects (PIPs), and require mechanisms to detect both underutilization and overutilization of services. Ongoing PIPs are typical and include measuring performance using objective quality indicators; implementation of interventions to achieve improvement in quality; evaluation of the effectiveness of the interventions, and planning and initiating activities for increasing or sustaining improvement. PIPs can be focused on either clinical or non-clinical services. Healthcare Effectiveness Data and Information Set (HEDIS®) measures and the requirements of the National Committee for Quality Assurance (NCQA) are also considered, whether clinically based or service related. Finally, we are committed to working collaboratively with Network Physicians and Hospitals to identify Preventable Adverse Events (PAE) as a means of improving the quality and safety of patient care. Accreditation Anthem maintains health plan accreditation through the National Committee for Quality Assurance (NCQA). Accreditation is a process for an impartial organization to review a company's operations to ensure it is conducting business consistent with national standards. Accreditation fulfills State regulatory requirements, in some instances serving as a substitute for meeting a state’s quality requirements. It Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 19: Page 200 Chapter 19: Quality Assessment & Performance Improvement Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan also supports continuous improvement, guiding the plan to measure, analyze, report and improve the quality of services provided to members. National evaluations of health plan performance and customer satisfaction are driven by NCQA and used in the accreditation process. Two of the most important measures of performance and member satisfaction are the Healthcare Effectiveness Data and Information Set (HEDIS®) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®). HEDIS® is a set of standardized performance measures used to compare the performance of managed care plans and measures for physicians based on value rather than cost. More than 90% of America’s health plans use the HEDIS® tool and report rates annually. The CAHPS® survey is a member satisfaction survey administered annually to a random sample of adult members over the age of 18 enrolled in the Healthy Indiana Plan Medicaid program; adult members over the age of 18, and to the parents of children enrolled in the Hoosier Healthwise Medicaid program. Individual plan scores are compared to other health plans’ scores on specific measures for benchmarking purposes. Accreditation results are displayed on public websites; these “report cards” assist employers and individual consumers to make informed decisions about their health plan options based on quality and value. Quality Assessment and Performance Improvement Quality Improvement Program Anthem’s QAPI program focuses on developing and implementing standards for clinical care and service, measuring conformity to those standards and taking action to improve performance. The scope of the QAPI program includes, but is not limited to, the monitoring and evaluation of: Utilization Management, Disease Management and Maternity Management Programs Case Management of members with complex health conditions Behavioral Health Programs Clinical Practice and Preventive Health Guidelines Patient safety Coordination of medical and behavioral health care Access and availability of services and practitioners Facility site review Medical record review Pharmacy and Therapeutics Provider/Member satisfaction Service quality Health equities, and Cultural and Linguistic Program Complaints, grievances and appeals Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 19: Page 201 Chapter 19: Quality Assessment & Performance Improvement Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan The QAPI program is defined within three quality documents that support program excellence: 1. Quality Improvement Program Description (QIPD): Describes the overall health plan approach to Quality Improvement (QI), what is to be accomplished (goals and objectives) and how the QAPI Program will be managed and monitored by the organization. 2. QI Work Plan: Lists the various quality interventions and activities, and how the goals/objectives are tracked and monitored throughout the year through reports to the quality committees. 3. QI Evaluation: The annual reporting method used to evaluate the progress and results of planned activities toward established goals. It describes the accomplishments of the QAPI Program and QI Work Plan. Each year as part of the continuous quality improvement (CQI) process, Anthem: Reviews its QAPI Program Description Establishes goals/objectives for its QI activities and implements a QI Work Plan to improve the level of care and service provided to its members Conducts a QAPI Evaluation to assess the effectiveness of the activities implemented throughout the year, and determines if the goals and objectives were met QAPI Program revisions are made based on outcomes, trends, contractual, accreditation, and regulatory standards and requirements, and overall satisfaction with the effectiveness of the program. Providers support the activities of the QAPI Program by: Completing corrective action plans, when applicable Participating in the facility site review and medical record review processes Providing access to medical records for quality improvement projects and studies Responding in a timely manner to requests for written information and documentation if a quality of care or grievance issue has been filed Using Preventive Health and Clinical Practice Guidelines in member care Quality Assessment and Performance Improvement Healthcare Effectiveness Data and Information Set (HEDIS) Practitioners and providers must allow Anthem to use performance data in cooperation with our quality improvement program and activities. Practitioner/Provider Performance Data refers to compliance rates, reports and other information related to the appropriateness, cost, efficiency and/or quality of care delivered by an individual healthcare practitioner, such as a physician, or a healthcare organization, such as a hospital. Common examples of performance data include the Healthcare Effectiveness Data and Information Set (HEDIS), quality of care measures maintained by the National Committee for Quality Assurance (NCQA) and the comprehensive set of measures maintained by the National Quality Forum (NQF). Practitioner/Provider Performance Data may be used for multiple plan programs and initiatives, including by not limited to: Reward Programs - Pay for Outcome (P4O), pay for value (PFV) and other results-based reimbursement programs that tie provider or facility reimbursement to performance against a Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 19: Page 202 Chapter 19: Quality Assessment & Performance Improvement Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan defined set of compliance metrics. Reimbursement models include but are not limited to shared savings programs, enhanced fee schedules and bundled payment arrangements. Recognition Programs - Programs designed to transparently identify high value providers and facilities and make that information available to consumers, employers, peer practitioners and other healthcare stakeholders. Anthem is ready to help when Providers and their office staff need training to participate in required HEDIS evaluations. Providers can request consultations and training in the following areas: Information about the year’s selected HEDIS studies How data for those measures will be collected Codes associated with each measure Tips for smooth coordination of medical record data collection Anthem’s Quality Improvement staff will contact the Provider’s office when we need to review or copy any medical records required for quality improvement studies. Office staff must provide access to medical records for review and copying. Quality Assessment and Performance Improvement Quality Management Over-utilization and under-utilization is reviewed annually utilizing HEDIS data. The purpose of Under and Over Utilization analysis is to facilitate the delivery of appropriate care by monitoring the impact of Utilization Management (UM) Programs as well as identify and correct potential over-utilization and under-utilization. The annual analysis of the data provides insight into the potential under and over utilization of services. Anthem utilizes the data to measure compliance with established goals and/or national averages/benchmarks where applicable. Quality Assessment and Performance Improvement Best Practice Methods Best practice methods are Anthem's most up-to-date compilation of effective strategies for quality health care delivery. We share best practice methods with Providers during Provider site visits. Quality and Provider Relations teams offer Anthem policies and procedures, along with educational toolkits, to help guide improvements. Toolkits may include examples of best practices from other offices, including: Resources for improving compliance with preventive health services Clinical practice guidelines Care for Members with special or chronic care needs Office Practice Optimizations Quality Assessment and Performance Improvement Member Satisfaction Surveys Anthem conducts Consumer Assessment of Healthcare Providers and Systems (CAHPS®) member satisfaction surveys each year through a contracted vendor certified by the NCQA. The CAHPS® survey includes “Rating” measures of members’ overall satisfaction with their health plan, all health care Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 19: Page 203 Chapter 19: Quality Assessment & Performance Improvement Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan received, personal doctor and specialists. Other areas of assessment include ease of accessing care, quality of physician services, customer service and claims processing. Our privately-contracted survey allows Anthem to add additional questions to the survey to help us better understand our members’ perceptions and enable the development of meaningful interventions. CAHPS® survey results (scores) are compared to the previous years’ scores as well as to the NCQA Quality Compass®. This is a database maintained by NCQA that includes results from all CAHPS® health plan surveys nationwide as well as National Averages & Percentiles. Opportunities for improvement are identified and priorities are set based on the review and analysis of scores, and also consider those areas where the Plan can make the greatest impact. Recommendations for prioritizing the focus areas for improvement are reviewed with the appropriate quality committees and stakeholders. Anthem shares the results of the CAHPS® survey with providers annually through an article in our Provider newsletter. Providers are encouraged to review the results, share them with office staff, and address any areas of deficiency in their offices. On an annual basis, member satisfaction is comprehensively analyzed by combining the results of CAHPS® surveys with member complaints, grievances and appeals. Together these important barometers of member satisfaction are considered when making plans for improving service and customer satisfaction. Quality Assessment and Performance Improvement Provider Satisfaction Surveys Anthem may conduct Provider surveys to monitor and measure Provider satisfaction with Anthem’s services and to identify areas for improvement. Provider participation in these surveys is highly encouraged and your feedback is very important. We inform Providers of the results and plans for improvement through Provider bulletins, newsletters, meetings or training sessions. Quality Assessment and Performance Improvement Medical Record and Facility Site Reviews Anthem conducts medical records and facility site reviews in order to determine: Provider compliance with standards for providing and documenting health care Provider compliance with standards for storing medical records Provider compliance with processes that maintain safety standards and practices Provider involvement in the continuity and coordination of Member care Please Note: The Indiana Family and Social Services Administration (FSSA) and Anthem have the right to enter into the premises of Providers to inspect, monitor, audit or otherwise evaluate the work performed. We perform all inspections and evaluations in such a manner as not to unduly delay work, in accordance with the Provider contract. Quality Assessment and Performance Improvement Medical Record Documentation Standards Anthem requires Providers to maintain medical records in a manner that is current, organized, and permits effective and confidential Member care and quality review. We perform random medical record Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 19: Page 204 Chapter 19: Quality Assessment & Performance Improvement Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan reviews of all Primary Care Providers (General Practice, Family Practice, Internal Medicine, Pediatrics and select Obstetrics/Gynecology) to ensure that network Providers are in compliance with these standards. Network Providers shall agree to maintain the confidentiality of Member information and information contained in a Member’s medical records according to the Health Information Privacy and Accountability Act (HIPPA) standards. Medical records must be stored and retrieved in a manner that protects patient information according to the Confidentiality of Medical Information Act, which requires the following: The act prohibits a Provider of health care from disclosing any individually identifiable information regarding a patient's medical history, mental and physical condition, or treatment without the patient's or legal representative's consent or specific legal authority. Records required through a legal instrument may be released without patient or patient representative consent. Providers must be familiar with the security requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and will only release such information as permitted by applicable federal, state and local laws and that is o Necessary to other Providers and the health plan related to treatment , payment or health care operations; or o Upon the Member’s signed and written consent Security The medical record must be secure and inaccessible to unauthorized access in order to prevent loss, tampering, disclosure of information, alteration or destruction of the record. Information must be accessible only to authorized personnel within the Provider’s office, Anthem, the Indiana Family and Social Services Administration, or to persons authorized through a legal instrument. Records must be made available to Anthem for purposes of quality review, HEDIS and other studies. Storage and Maintenance Active medical records shall be secured and must be inaccessible to unauthorized persons. Medical records are to be maintained in a manner that is current, detailed and organized, and that permits effective patient care and quality review while maintaining confidentiality. Inactive records are to remain accessible for a period of time that meets state and federal guidelines. Electronic record keeping system procedures shall be in place to ensure patient confidentiality, prevent unauthorized access, authenticate electronic signatures and maintain upkeep of computer systems. Security systems shall be in place to provide back-up storage and file recovery, to provide a mechanism to copy documents and to ensure that recorded input is unalterable. Availability of Medical Records The medical records system must allow for prompt retrieval of each record when the Member comes in for a visit. Providers must maintain Members' medical records in a detailed and comprehensive manner that accomplishes the following: Conforms to good professional medical practice Facilitates an accurate system for follow-up treatment Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 19: Page 205 Chapter 19: Quality Assessment & Performance Improvement Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Permits effective professional medical review and medical audit processes Medical records must be legible, signed and dated. They must be maintained for at least 7 years as required by state and federal regulations. Providers must offer a copy of a Member’s medical record upon reasonable request by the Member at no charge, and the Provider must facilitate the transfer of the Member’s medical record to another Provider at the Member’s request. Confidentiality of, and access to, medical records must be provided in accordance with the standards mandated in the Health Insurance Portability and Accountability Act (HIPAA) and all other state and federal requirements. Providers must permit Anthem and representatives of Indiana's Office for Medicaid Policy & Planning (OMPP) and Family and Social Services Administration (FSSA) to review Members’ medical records for the purposes of monitoring the Provider’s compliance with the medical record standards, capturing information for clinical studies, monitoring quality, or any other reason. OMPP encourages Providers to use technology, including health information exchanges, where appropriate, to transmit and store medical record data. Medical Record Documentation Standards Every medical record is, at a minimum, to include: The patient’s name or ID number on each page in the record Personal biographical data including home address, employer, emergency contact name and telephone number, home and work telephone numbers, and marital status All entries dated with month, day, and year All entries contain the author’s identification (for example, handwritten signature, unique electronic identifier or initials) and title Identification of all Providers participating in the Member’s care, and information on services furnished by these Providers A problem list, including significant illnesses and medical and psychological conditions Presenting complaints, diagnoses, and treatment plans, including the services to be delivered Physical findings relevant to the visit including vital signs, normal and abnormal findings, and appropriate subjective and objective information Information on allergies and adverse reactions (or a notation that the patient has no known allergies or history of adverse reactions) Information on advance directives Past medical history, including serious accidents, operations, illnesses, and for patients 14 years old and older, substance abuse (for children and adolescents, past medical history relates to prenatal care, birth, operation, and childhood illnesses) Physical examinations, treatment necessary and possible risk factors for the Member relevant to the particular treatment Prescribed medications, including dosages and dates of initial or refill prescriptions For patients 14 years and older, appropriate notations concerning the use of cigarettes, alcohol and substance abuse (including anticipatory guidance and health education) Information on the individuals to be instructed in assisting the patient Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 19: Page 206 Chapter 19: Quality Assessment & Performance Improvement Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Medical records must be legible, dated, and signed by the physician, physician assistant, nurse practitioner, or nurse midwife providing patient care An immunization record for children that is up-to-date or an appropriate history for adults Documentation attempts to provide immunizations. If the Member refuses immunization, proof of voluntary refusal of the immunization in the form of a signed statement by the Member or guardian shall be documented in the Member’s medical record Evidence of preventive screening and services in accordance with Anthem’s preventive health practice guidelines Documentation of referrals, consultations, diagnostic test results, and inpatient records (evidence of the Provider’s review may include the Provider’s initials or signature and notation in the patient’s medical record of the Provider’s review and patient contact, follow-up treatment, instructions, return office visits, referrals, and other patient information) Notations of patient appointment cancellations or “No Shows” and the attempts to contact the patient to reschedule No evidence that the patient is placed at inappropriate risk by a diagnostic test or therapeutic procedure Documentation on whether an interpreter was used, and, if so, that the interpreter was also used in follow-up Quality Assessment and Performance Improvement Advance Directives Recognizing a person's right to dignity and privacy, our Members have the right to execute an advance directive, also known as a "Living Will," to identify their wishes concerning health care services should they become incapacitated. Providers may be asked to assist Members in procuring and completing the necessary forms. More information can be found under the Standards and Policies heading on the Provider Resources page of our website at www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Advance Directive documents should be on hand in the event a Member requests this information. Any request should be properly noted in the Medical Record. Quality Assessment and Performance Improvement Medical Record Review Process Anthem’s Quality team will call the Provider’s office to schedule a medical record review on a date and time that will occur within 30 days of the initial call. On the day of the review, the Quality team member will: 1. 2. 3. 4. Request the number and type of medical records required. Review the appropriate type and number of medical records per Provider. Complete a medical record review. Meet with the Provider or office manager to review and discuss the results of the medical record review. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 19: Page 207 Chapter 19: Quality Assessment & Performance Improvement Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan 5. Provide a copy of the medical record review results to the office manager or doctor, or sends a final copy within 10 days of the review. 6. Schedule follow-up reviews for any corrective actions identified. Providers must attain a score of 80% or greater in order to pass the medical record review. Anthem completes a random medical record review annually according to our medical records standards. Quality Assessment and Performance Improvement Facility Site Review Process Anthem will conduct a facility site review (FSR) and inspection if three (3) formal complaints have been received by members for a Primary Medical Provider. An FSR inspection consists of 13 elements, which include: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Accessibility Appearance Safety and Infectious waste Office Policies Provider Availability Treatment areas Patient services Process of documentation Personnel Medications , to include emergency supplies Referral process Medical records elements and organization Appointment accessibility Anthem’s Quality team will call the Provider’s office to schedule an appointment date and time for the facility site review. The Practice Consultants will fax or mail a confirmation letter with an explanation of the audit process and required documentation. During the facility site review, the Quality staff will: 1. Lead a pre-review conference with the Provider or office manager to review and discuss the process of facility review and answer any questions. 2. Conduct the review of the facility. 3. Complete the facility site review. 4. Develop a corrective action plan, if applicable. After the facility site review is completed, Anthem’s Practice Consultants will meet with the Provider or office manager to: 1. Review and discuss the results of the facility site review and explain any required corrective actions. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 19: Page 208 Chapter 19: Quality Assessment & Performance Improvement Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan 2. Provide a copy of the facility site review results and the corrective action plan to the office manager or Provider. The Practice Consultants may send a final copy within 10 days of the review. 3. Educate the Provider and office staff about Anthem’s standards and policies. 4. Schedule a follow-up review for any corrective actions identified. Providers must attain a score of 80% or greater to pass. Quality Assessment and Performance Improvement Facility Site Review: Corrective Actions If the facility site review results in a non-passing score, Anthem will immediately notify Providers of the non-passing score, all cited deficiencies and corrective action requirements. The Provider offices will develop and submit corrective action plans and Anthem will conduct follow-up visits every 6 months until the site complies with Anthem standards. The Provider and office staff will: 1. 2. 3. 4. 5. 6. Provide an appointment time for the review. Be available to answer questions and participate in the exit interview. Schedule follow-up reviews, if applicable. Complete a corrective action plan. Sign an attestation that corrective actions are complete. Submit the completed corrective action plan, supporting documents and signed attestation to our Clinical Quality Compliance Administrator. Quality Assessment and Performance Improvement Preventable Adverse Events The breadth and complexity of today’s health care system means there are inherent risks, many of which can be neither predicted nor prevented. However, when there are preventable adverse events, they should be tracked and reduced, with the ultimate goal of eliminating them. Providers and health care systems, as advocates for our Members, are responsible for the continuous monitoring, implementation and enforcement of applicable health care standards. Focusing on patient safety, we work collaboratively with Providers and hospitals to identify preventable adverse events and to implement appropriate strategies and technologies to avoid them. Our goal is to enhance the quality of care received not only by our Members but all patients receiving care in these facilities. Prevention of adverse events may require the disclosure of protected health information. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) specifies that Protected Health Information (PHI) can be disclosed for the purpose of health care operations in relation to quality assessment and improvement activities. Moreover, the information you share with us is legally protected through the peer review process; as such, it will be maintained in a strictly confidential manner. If you receive a request for medical records, please provide them within 10 days from the date of request. We will continue to monitor activities related to the list of adverse events from federal, state, and private payers, including “Never Events.” Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 19: Page 209 Chapter 19: Quality Assessment & Performance Improvement Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Preventable adverse events should not occur. When they do, we firmly support the concept that a health plan and its Members should not pay for resultant services. Please Note: Medicaid is prohibited from paying for certain Health Care Acquired Conditions (HCAC). This applies to all hospitals. *Never Events: As defined by the National Quality Forum (NQF), are adverse events that are serious, but largely preventable, and of concern to both the public and health care providers. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 19: Page 210 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 20: ENROLLMENT AND MARKETING RULES Hoosier Healthwise: Phone: Hours of Operation: Website: 1-800-403-0864 Monday to Friday, 7am-7pm Healthy Indiana Plan: Phone: Hours of Operation: Website: 1-877-GET-HIP-9 (1-877-438-4479) Monday to Friday, 7am-8pm www.indianamedicaid.com www.in.gov/fssa/hip/ Enrollment and Marketing Rules Overview The delivery of quality health care poses numerous challenges, not least of which is the commitment shared by Anthem and its Providers to protect our Members. We want our Members to make the best health care decisions possible for themselves and their families. When they ask for our assistance, we want to help them make those decisions without undue influence. Anthem recognizes that Providers occupy a unique, trusted and respected part of people’s lives. Given the complexity of modern-day healthcare and the inherent difficulties communicating with some of the populations we serve, there are potentially serious pitfalls when Anthem or network Providers try to assist in the decision-making process. Sometimes, even though the intent is to help make our Members’ lives better, we can overstep. For that reason, we are committed to following strict enrollment and marketing guidelines created by the Indiana Family and Social Services Administration (FSSA), and to honoring the rules for all state health care programs. Enrollment and Marketing Rules Marketing Policies Anthem Providers are prohibited from making marketing presentations and advising or recommending to an eligible individual that he or she select membership in a particular plan. The Indiana Family and Social Services Administration marketing practice policies prohibit Providers from making the following false or misleading claims: That the Primary Medical Provider’s office staff are employees or representatives of the state, county or federal government That Anthem is recommended or endorsed by any state or county agency, or any other organization That the state or county recommends that a prospective Member enroll with a specific health care plan That a prospective Member or medical recipient loses Medicaid or other welfare benefits if the prospective Member does not enroll with a specific health care plan These policies also prohibit Providers from taking the following actions: Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 20: Page 211 Chapter 20: Enrollment & Marketing Rules Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Offering or giving away any form of compensation, reward or loan to a prospective Member to induce or procure Member enrollment in a specific health care plan. Engaging in direct marketing to Members that is designed to increase enrollment in a particular health care plan. The prohibition should not constrain Providers from engaging in permissible marketing activities consistent with broad outreach objectives and application assistance. Using any list of Members obtained originally for enrollment purposes from confidential state or county data sources, or from the data sources of other contractors. Employing marketing practices that discriminate against potential Members based on marital status, age, religion, sex, national origin, language, sexual orientation, ancestry, pre-existing psychiatric problem or medical condition (such as pregnancy, disability or acquired immune deficiency syndrome), other than those specifically excluded from coverage under our contract. Reproducing or signing an enrollment application for the Member. Displaying materials only from the Provider’s contracted managed health care organizations and excluding others. Providers are permitted to: Assist the Member in applying for benefits by directing him or her to call the Hoosier Healthwise or Healthy Indiana Plan help lines for enrollment information: Hoosier Healthwise: 1-800-403-0864 Healthy Indiana Plan: 1-877-GET-HIP-9 (1-877-438-4479) Distribute copies of HIP applications to potential Members. File a complaint with Anthem if a Provider or Member objects to any form of marketing, either by other Providers or by Anthem representatives. (Please refer to the Grievances and Appeals chapter of this manual for more information on the grievance process.) Enrollment and Marketing Rules Enrollment Process The Indiana Family and Social Services Administration (FSSA) determines the eligibility and enrollment for Hoosier Healthwise and Healthy Indiana Plan Members. Then the process is as follows: The FSSA presents managed health care plan options to individuals and families eligible for Hoosier Healthwise and the Healthy Indiana Plan. Eligible Members enroll in the plan of their choice and select a Primary Medical Provider. If, after 14 calendar days, the Member has not selected a Primary Medical Provider, Anthem assigns a Primary Medical Provider to the Member. For Hoosier Healthwise, the parent or guardian completes applications and makes selections on behalf of children eligible for Early and Periodic Screening, Diagnostic and Treatment Services. The enrollment broker informs Anthem of new Member enrollment, and after enrollment, of any changes in Member eligibility, status or contact information (such as change of address). Providers are given notice of new Members assigned to their care through Anthem monthly eligibility reports. Providers can access these reports by logging into our secure website, MyAnthem, located at www.anthem.com. Anthem sends each new Member a New Member Kit within 5 business days after receiving the FSSA's monthly membership file. This kit includes a Member identification (ID) card, letter and Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 20: Page 212 Chapter 20: Enrollment & Marketing Rules Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Primary Medical Provider choice or assignment. The ID card includes Primary Medical Provider contact information as well as the procedures for changing a Primary Medical Provider. Please Note: FSSA will automatically re-enroll any Member who loses Hoosier Healthwise eligibility but becomes eligible again within six months or less. Members will automatically return to the same health care plan and Primary Medical Provider that they had prior to disenrollment, if available. Members may choose to switch plans. Please Note: To support the Member enrollment process, Primary Medical Providers are encouraged to maintain open panels. The state requires that 80% of Anthem Primary Medical Providers have open panels; your open panel will assist us in meeting this requirement. ** Open Panels: The commitment by Anthem-contracted Providers to accept new Anthem Members. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 20: Page 213 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 21: FRAUD, ABUSE AND WASTE Hoosier Healthwise Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-8pm Fraud, Abuse and Waste Overview We are committed to protecting the integrity of our health care program and the efficiency of our operations by preventing, detecting and investigating fraud, abuse and waste. Fraud, Abuse and Waste Understanding Fraud, Abuse and Waste Combating fraud, abuse and waste begins with knowledge and awareness. **Fraud: Any type of intentional deception or misrepresentation made with the knowledge that the deception could result in some unauthorized benefit to the person committing it -- or any other person. The attempt itself is fraud, regardless of whether or not it is successful. **Abuse: Any practice inconsistent with sound fiscal, business or medical practices that results in an unnecessary cost to the Medicaid program, including administrative costs from acts that adversely affect Providers or Members. **Waste: Generally defined as activities involving careless, poor or inefficient billing or treatment methods causing unnecessary expenses and/or mismanagement of resources. Fraud, Abuse and Waste Examples of Provider Fraud, Abuse and Waste The following are examples of Provider fraud, abuse and waste: • Altering medical records • Billing for services not provided • Billing for medically unnecessary tests • Billing professional services performed by untrained personnel • Misrepresentation of diagnosis or services • Over-utilization • Soliciting, offering or receiving kickbacks or bribes • Unbundling • Under-utilization • Upcoding Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 21: Page 214 Chapter 21: Fraud, Abuse & Waste Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Fraud, Abuse and Waste Examples of Member Fraud, Abuse and Waste The following are examples of Member fraud, abuse and waste: • Disruptive or threatening behavior • Frequent emergency room visits for non-emergent conditions • Forging, altering or selling prescriptions • Letting someone else use a Member’s Hoosier Healthwise or Healthy Indiana Plan ID • Not telling the truth about the amount of money or resources the Member has in order to get benefits • Not telling the truth about a medical condition to get medical treatment • Obtaining controlled substances from multiple Providers • Relocating to out-of-service area • Using more than one Provider to obtain similar treatments and/or medications • Using a Provider not approved by the Primary Medical Provider • Using someone else’s Hoosier Healthwise or Healthy Indiana Plan ID • Violation of the Pain Management Contract **Pain Management Contract: A written agreement between a Provider and Member that the Member will not misrepresent his or her need for medication. If the contract is violated, the Provider has the right to drop the Member from his or her practice. Fraud, Abuse and Waste Reporting Provider or Recipient Fraud, Abuse or Waste If you suspect either a Provider (doctor, dentist, counselor, etc.) or Member (a person who receives benefits) has committed fraud, abuse or waste, you have the right and responsibility to report it. Providers can report allegations of fraud, abuse or waste by the following: Call Anthem at: 1-866-408-6132. Complete a Fraud Referral Form, found in the Forms Library on the Provider Resources page of our website, www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. When complete, fax it to: 1-866-408-7087 Or mail it to: Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 Members should let us know if they suspect a Provider, Dentist, Pharmacist, other health care Providers--or another person receiving benefits--is doing something wrong. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 21: Page 215 Chapter 21: Fraud, Abuse & Waste Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan To report fraud, abuse, or waste, choose one of the following: Call Indiana's Office of the Inspector General (OIG) Hotline at: 1-800-HHS-TIPS (1-800-447-8477) Report directly to Anthem: By phone at: 1-866-408-6132 By fax: 1-866-454-3990 Online: www.anthem.com By mail at: Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN 46206-6144 When reporting on a Provider (a Doctor, Dentist, Counselor, etc.) include: • Name, address, and phone number of Provider Name and address of the facility (hospital, nursing home, home health agency, etc.) Medicaid number of the Provider and facility, if you have it Type of Provider (Doctor, Dentist, Therapist, Pharmacist, etc.) Names and phone numbers of other witnesses who can help in the investigation Dates of events Summary of what happened When reporting about a Member who receives benefits, include: • The person’s name The person’s date of birth, Social Security number, or case number if you have it The city where the person lives Specific details about the fraud, abuse or waste Fraud, Abuse and Waste Anonymous Reporting of Suspected Fraud, Abuse and Waste Any incident of fraud, abuse or waste may be reported to us anonymously; however, in certain instances, we may not be able to pursue an investigation without additional information. In such cases, we will need the following: • • The name of the person reporting and their relationship to the person suspected A call-back phone number for the person reporting the incident Please Note: The name of the person reporting the incident and his callback number will be kept in strict confidence by investigators to maintain that person's anonymity. Fraud, Abuse and Waste Investigation Process We do not tolerate acts that adversely affect Providers or Members. We investigate all reports of fraud, abuse and waste. Allegations and the investigative findings are reported to the Indiana Family and Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 21: Page 216 Chapter 21: Fraud, Abuse & Waste Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Social Services Administration (FSSA) as well as regulatory and law enforcement agencies. In addition to reporting, we take corrective action, such as: Written warning and/or education: We send certified letters to the Provider or Member documenting the issues and the need for improvement. Letters may include education, request for recoveries, or may advise of further action. Medical record audit: We may review medical records to substantiate allegations or validate claims submissions. Special claims review: A special claims review places payment or system edits on file to prevent automatic claim payment; this requires a medical reviewer evaluation. Recoveries: We recover overpayments directly from the Provider within 30 days. Failure of the Provider to return the overpayment may be reflected in reduced payment of future claims or further legal action. Fraud, Abuse and Waste Acting on Investigative Findings We refer all criminal activity, be it Member or Provider, to the appropriate regulatory and law enforcement agencies. If a Provider has committed fraud, abuse or waste, the Provider: • Will be referred to the Quality Management department May be presented to the credentials committee and/or peer review committee for disciplinary action, including Provider termination Failure to comply with program policy, procedures or any violation of the contract will result in termination from our plan. If a Member has committed fraud, exhibited abusive or threatening behavior, or has failed to correct issues, he or she may be involuntarily disenrolled from our health care plan, with state approval. (Refer to the Member Transfers chapter for more information on the disenrollment process.) Fraud, Abuse and Waste False Claims Act We are committed to complying with all applicable federal and state laws, including the federal False Claims Act (FCA). The False Claims Act is a federal law that allows the government to recover money stolen through fraud by government contractors. Under the FCA, anyone who knowingly submits or causes another person or entity to submit false claims for payment of government funds is liable for three times the damages, or loss, to the government, plus civil penalties of $5,500 to $11,000 per false claim. The FCA also contains Qui Tam or “whistleblower” provisions. A “whistleblower” is an individual who reports in good faith an act of fraud or waste to the government or files a lawsuit on behalf of the government. Whistleblowers are protected from retaliation from their employer under Qui Tam provisions in the FCA and may be entitled to a percentage of the funds recovered by the government. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 21: Page 217 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 22: MEMBER RIGHTS & RESPONSIBILITIES Hoosier Healthwise Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6131 or 1-866-408-7188 (TTY) 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-866-408-6131 or 1-866-408-7188 (TTY) 1-866-408-7087 Monday to Friday, 7am-7pm Member Rights & Responsibilities Overview Members should be clearly informed about their rights and responsibilities in order to make the best health care decisions. That includes the right to ask questions about the way we conduct business, as well as the responsibility to learn about their health care coverage. The following Member rights are defined by the state of Indiana and appear in the Anthem Member welcome packets and Member Handbook. They are also posted on our website at: www.anthem.com > under OTHER ANTHEM WEBSITES, select Providers > Under Providers/Spotlight select State-Sponsored Plans – Indiana Hoosier Healthwise and Health Indiana Plan >Select Indiana Hoosier Healthwise and Healthy Indiana Plan (HIP) >scroll down to Forms and Tools >select Member Rights and Responsibilities >go to the chapter of the Provider Manual for the current version. Member Rights & Responsibilities Member Rights Members have the right to: Be treated with respect and dignity Expect us to keep their personal health information private, as long as it follows state and federal laws and our privacy policies Get the help they need to understand their Member handbook Get the information they need to help make sure they get the most from their health plan, including information on: o Our company and services o Our network of doctors and other health care providers o Your rights and responsibilities Access their medical records, as allowed by federal and state laws Work with doctors in making choices about health care Speak freely and privately with their doctor about all health care options and treatment needed for their condition, no matter what the cost or whether it is covered under their plan Find out how we decide if new technology should be part of a benefit Have problems taken care of fast. This includes things they think are wrong. It also includes issues that have to do with their coverage, payment of services or getting an okay from Anthem Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 22: Page 218 Chapter 22: Member Rights & Responsibilities Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Know that the date they joined Anthem is used as the date when their benefits begin. Anthem will not cover services they received before the date they joined the health plan Be treated the same as others Get care that is medically necessary Have access to medical advice from their doctor, either in person or by phone, 24 hours a day, 7 days a week. This includes emergency or urgent care Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation Choose a Primary Medical Provider who is part of the network Change their Primary Medical Provider without cause or reason Be told which hospitals they can use and have access to them Get interpreter services at no charge if they speak a language other than English or if they have hearing, vision or speech loss Request oral interpretation and translation services during doctor appointments at no charge Get information in other formats such as Braille, large-size print or audio upon request and at no charge Make a complaint or file an appeal about: o Their health care plan o Any care they get o Any covered service or benefit their health plan makes File an appeal with the State Medicaid Office for Hearings and Appeals if they are not pleased with the final decision after using Anthem’s grievance procedure. Know Providers can challenge the denial of services if the Member says it's okay Refuse care from their Primary Medical Provider or other health care Providers Make an Advance Directive, also called a "living will" Ask about our quality program and tell us if they would like to see changes made Ask us how we do utilization review and give us ideas for changing it Know that we cover only health care services that are part of their plan Know that if they receive services from a Provider not contracted with us, those services may not be covered Know that laws guide the health plan and the services they receive Know they will not be held liable if the health plan cannot pay for their treatment Know that we can make changes to their health plan benefits as long as we tell them about those changes in writing before they take effect Know that Anthem, their doctors and other health care Providers cannot treat them differently because of: o Age o Sex o Race o National Origin Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 22: Page 219 Chapter 22: Member Rights & Responsibilities o o Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Language Needs Degree of your Illness or Health Condition Know that Anthem does not take the place of workers' compensation insurance Additional Rights for Members of the Healthy Indiana Plan: Healthy Indiana Plan Members have the following additional rights: The right to choose or allow another person to act on their behalf, even if they are physically or mentally unable to give their approval The right to know their POWER Account balance at any time The right to know what preventive services are needed to roll-over their POWER Account The right to change plans or disenroll from this plan before their first POWER Account payment is made or within 60 days after being assigned to our plan (whichever comes first) The right to disenroll from this plan for any of these reasons: o Unfair delay by Anthem in giving an approval requested ahead of time by the Member o Access to care issues (such as Anthem’s network Providers not taking new patients) o Anthem’s failure to provide covered services o Language or cultural problems that cannot be resolved o Corrective action charged against Anthem by the Office of Medicaid Policy & Planning (OMPP) Member Rights & Responsibilities Member Responsibilities Members have the following responsibilities: To know and follow the rules of the health plan To give their doctors the information needed to get the best care possible To follow the care plan that they agreed on with their doctors To understand their health problems and work with their doctors to make a treatment plan that they agree on To treat their doctor and other health care Providers with respect To make appointments with their doctor when needed To keep all scheduled appointments To be on time for appointments To call their doctor if they cannot make it to an appointment To always call their Primary Medical Provider first for all of their medical care, unless there is an emergency To show their ID cards each time they get medical care To use the emergency room only for true emergencies To pay for services that are not covered by Anthem, including copays To tell us and their social worker if: o They move Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 22: Page 220 Chapter 22: Member Rights & Responsibilities o o o o Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Change their phone number Have any changes to their insurance The number of people in their household changes They become pregnant Additional Responsibilities for Members of the Healthy Indiana Plan: Members must make their monthly payments on time Members must know their health care benefits such as out-of-area coverage and copays Members must give true and complete details about other health care coverage and/or insurance benefits they may have Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 22: Page 221 Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan CHAPTER 23: CULTURAL DIVERSITY & LINGUISTIC SERVICES Hoosier Healthwise: Anthem Medicaid Provider Helpline Phone: Anthem Medicaid Provider Helpline Fax: Hours of Operation: 1-866-408-6132 1-866-408-7087 Monday to Friday, 7am-7pm Healthy Indiana Plan: Anthem Provider Helpline Phone: Anthem Provider Helpline Fax: Hours of Operation: 1-800-345-4344 1-800-376-0247 Monday to Friday, 7am-7pm Cultural Diversity & Linguistic Services Overview At Anthem, we recognize that providing health care services to a diverse population can present challenges. Those challenges arise when Providers need to cross a cultural divide to treat Members who may have different behaviors, attitudes and beliefs concerning health care. Differences in our Members' ability to read may add an extra dimension of difficulty when Providers try to encourage follow-through on treatment plans. Anthem's Cultural Diversity and Linguistic Services Toolkit, called "Caring For Diverse Populations," was developed to give you specific tools for breaking through cultural and language barriers in an effort to better communicate with your patients. Sometimes the solution is as simple as finding the right interpreter for an office visit. Other times, a greater awareness of cultural sensitivities can open the door to the kind of interaction that makes treatment plans most effective: Has the patient been raised in a culture that frowns upon direct eye contact or receiving medical treatment from a member of the opposite sex? Is the patient self-conscious about his or her ability to read instructions? This toolkit gives you the information you'll need to answer those questions and continue building trust. It will enhance your ability to communicate with ease, talking to a wide range of people about a variety of culturally sensitive topics. And it offers cultural and linguistic training to your office staff so that all aspects of an office visit can go smoothly. We strongly encourage you to access the complete Health Education: Caring for Diverse Populations toolkit on the Provider Resources page of our website, www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. The toolkit contents are organized into the following sections: Improving Communications with a Diverse Patient Base Encounter tips for Providers and their clinical staff A mnemonic to assist with patient interviews Help in identifying literacy problems Tools and Training for Your Office in Caring for a Diverse Patient Base Interview guide for hiring clinical staff who have an awareness of cultural competency issues Availability of Medical Consumerism training for health educators to share with patients Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 23: Page 222 Chapter 23: Cultural Diversity & Linguistic Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan Resources to Communicate Across Language Barriers Tips for locating and working with interpreters Common signs and common sentences in many languages Language identification flashcards Language skill self-assessment tools Primer on How Cultural Background Impacts Health Care Delivery Tips for talking with people across cultures about a variety of culturally sensitive topics Information about health care beliefs of different cultural backgrounds Regulations and Standards for Cultural and Linguistic Services Identifies some important legislation impacting cultural and linguistic services including a summary of the “Culturally and Linguistically Appropriate Service” standards (CLAS) which serve as a guide on how to meet these requirements Resources for Cultural and Linguistic Services A bibliography of print and Internet resources for conducting an assessment of the cultural and linguistic Needs of your own practice’s patient population Staff and physician cultural and linguistic competency training resources Links to additional tools in multiple languages and/or written for limited English proficiency This toolkit contains materials developed by and used with the permission of the Industry Collaboration Effort (ICE) Cultural and Linguistic Workgroup, a volunteer, multi-disciplinary team of Providers, health plans, associations, state and federal agencies and accrediting bodies working collaboratively to improve health care regulatory compliance through public education. More information on the ICE Workgroup may be obtained on the ICE Workgroup website: www.iceforhealth.org. Cultural Diversity & Linguistic Services Interpreter Services For those instances when you cannot communicate with a Member due to language barriers, interpreter services, including over-the-phone and face-to-face interpreters, are available at no cost to you or the Member. Providers must notify Members of the availability of interpreter services and strongly discourage the use of friends and family, particularly minors, to act as interpreters. Face-to-face interpreters for Members needing language assistance, including American Sign Language, are available by placing a request at least 72 hours in advance. A 24-hour cancellation notice is required. To request interpreter services, Providers and Members should call: Anthem Medicaid Provider Helpline: 1-866-408-6132 Customer Care Center (Members): 1-866-408-6131 For after hours interpreter services, call 24/7 NurseLine: 1-866-800-8780 or 1-800-368-4424 (TTY) and follow these steps: 1. Give the Customer Care associate the Member’s ID number Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 23: Page 223 Chapter 23: Cultural Diversity & Linguistic Services Anthem Blue Cross and Blue Shield Hoosier Healthwise and Healthy Indiana Plan 2. Explain the need for an interpreter and state the language 3. Wait on the line while the connection is made 4. Once connected to the interpreter, the associate or 24/7 NurseLine nurse introduces the Member, explains the reason for the call and begins the dialogue TTY and Relay Services (for Members with Hearing Loss or Speech Impairment) During business hours, call Anthem’s TTY line at 1-866-408-7188. The Indiana relay service is available 24 hours a day by calling 1-800-743-3333 or 711. For additional information on interpreter services, please go to the Health Education: Interpreter Services section on the Provider Resources page of our website, www.anthem.com. For directions on how to access the Provider Resources page of our website, please see Chapter 1: How to Access Information, Forms and Tools on Our Website. Anthem Blue Cross and Blue Shield Indiana Medicaid Provider Manual Hoosier Healthwise and Healthy Indiana Plan Version 2.2 June 1, 2014 Chapter 23: Page 224 THIS PAGE LEFT INTENTIONALLY BLANK Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AIN-PM-0001-14 1013032 0514
© Copyright 2024